Registration INFORMATION ABOUT THE PERSON COMPLETING THIS FORMForm completed by Doctor/parent/caregiver/patient Role*DoctorParentCaregiverPatient Username* Password* The password must be at least 7 characters.Please enter the password again* Email*INFORMATION ABOUT THE PATIENT Name* Last Name* Date of Birth* Gender*FemaleMale The date supplementation with Augmented NAC began* Number of Augmented NAC capsules taken daily ** Diagnosis*CovidLong CovidInjured by Covid-vaccineOther Medications Other SupplementsBelow is the field to enter the patient's first symptom. You can enter up to 5 symptoms (individually). When you finish entering information in the field for symptom 1 and press enter, more fields will appear to fill in, along with a field for symptom 2 and so on. Enter symptoms and score them from 0 to 5, where 0 is asymptomatic and 5 is very severe, from day 0, the first day the patient began taking Augmented NAC, to day 3 and up to 30 days. Symptom 1 Day 0Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 3Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 7Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 10Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 15Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 21Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 30Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Symptom 2 Day 0Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 3Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 7Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 10Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 15Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 21Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 30Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Symptom 3 Day 0Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 3Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 7Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 10Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 15Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 21Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 30Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Symptom 4 Day 0Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 3Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 7Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 10Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 15Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 21Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 30Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Symptom 5 Day 0Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 3Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 7Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 10Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 15Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 21Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Day 30Please score symptoms 0-5 where 0 is asymptomatic and 5 is very severe. Comments By submitting this form you confirm that you have read and understood our Privacy Policy. Select a payment method *
