Infection Symptoms Checklist – Nikolenko Clinic

First Name *

Last Name

How can we apply to you? *

Mr

Mrs

Ms

Other

How old are you? *

Do you have unexplained fevers, sweats, chills, or flushing *

Do you have unexplained weight change…..Loss or Gain *

Do you have fatigue or tiredness especially morning hours? *

Have you been vaccinated for Covid-19? *

Do you have unexplained hair loss (men and women)? *

Swollen glands *

Sore throat *

Testicular pain / Pelvic Pain *

Unexplained menstrual irregularity, disruption to menstrual cycle, amenorrhea *

Unexplained breast milk production, breast pain *

Irritable bladder or bladder dysfunction *

Sexual dysfunction / loss of libido *

Upset stomach *

Change in bowel function (Constipation or Diarrhea) *

Chest pain or Rib soreness *

Shortness of Breath / Cough *

Heart palpitations, pulse skips, heart block *

History of Heart Murmur or Valve Prolapse *

Joint pain or Swelling *

Stiffness of the neck or back *

Muscle pain or cramps *

Twitching of the face or other muscles *

Headaches or Migraines *

Neck cracks or Neck Stiffness *

Tingling, numbness, burning or stabbing sensations *

Facial Paralysis (Bells Palsy) *

Eyes/Vision – Double, Blurry *

Ears/Hearing – Buzzing, Ringing, Ear Pain *

Increased motion sickness, vertigo *

Light theadedness, poor balance, difficulty walking *

Tremors *

Confusion, difficulty thinking or Brain Fog *

Difficulty with concentration or reading *

Forgetfulness, poor short term memory *

Disorientation; getting lost, going to wrong places *

Difficulty with speech or writing *

Mood swings, irritability, depression *

Disturbed sleep – Too Much, Too Little, Early Awake *

Exaggerated symptoms or worse hangover from alcohol *

You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia? *

Yes

No

You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder? *

Yes

No

Thinking about your overall physical health, for how many of the past thirty days was your physical health not good? *

0-5 days

6-12 days

13-20 days

21-30 days

Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good? *

0-5 days

6-12 days

13-20 days

21-30 days

Email *

Contact PHONE number starting with area code (Example: 357 99123456 or 61 – Australia or 44 – UK)

GDRP Agreement. I consent to having this website my submitted information so they can respond to my inquiry *

I agree

Comprehensive online viral or bacterial infection checklist.

Helps to predefine possible course of the disease based on symptoms.

Complete the form and get doctor’s feedback for free!