Cold & Flu

Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

Have you been exposed to someone with flu or flu symptoms?*

Yes
No

Have you been tested for flu recently?*

Yes
No

What was the result?*

Positive Result
Negative Result

What symptoms have you been experiencing recently?*

Please best explain the description of fever or chills:*

Feeling warm no measured temperature
Measured temperature of 100.8 degrees (fahrenheit) or higher
Severe uncontrollable chills (teeth chattering)

Unfortunately we cannot proceed with your request based on the information you have provided.

If you've listed "other", please explain your symptoms:*

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for cold & flu?*

Yes
No

How long ago?*

What medications were you treated with?*

Antihistamines
Nasal decongestants
Oral decongestants

What type of Oral decongestants?*

Pseudoephedrine
Oxymetazoline
Phenylephrine
Other

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

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