Leave your name and number if you want us to call you about this at-home COVID treatment study. Your information will not be used for anything else or given to others.
In what state did you get your COVID test?
Minnesota Indiana Colorado Illinois California other
Deje su nombre y número si desea que lo llamemos sobre este estudio de tratamiento COVID en el hogar. Su información no se utilizará para nada más ni se dará a otros.
Nombre: Número de teléfono:
¿En qué estado se hizo la prueba de COVID?
Minnesota Indiana Colorado Illinois California otro
Covid-Out is temporarily paused for enrollment, you may fill out the "request a callback" form on our website if you would like to be contacted about a similar clinical trial called Activ6. Or, you may visit their website for more information at activ6study.org.
Click through these questions to see if you are eligible for the study!
You can call or email the study at any time if you have questions.
Phone: 651-661-9560
Email:
[email protected] If you select an answer and receive an alert that "You have selected an option that triggers this survey to end right now", this means that you do not fit one of the eligibility criteria, and you are not eligible for this study. If you have questions about eligibility, please call 651-661-9560 or email
[email protected] .
First and Last
Have you had the Covid-19 booster?
Yes
No
Individuals who have received the booster are not eligible at this time. Please visit combatcovid.hhs.gov for the most information about other trials and treatments.
Have you received 2 doses of the Pfizer or Moderna vaccines, or 1 dose of the Johnson & Johnson vaccine, in the last 6 months?
Yes
No
What is your date of birth?
Today M-D-Y
Age at time of screening:
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When did you receive your second dose of the Moderna or Pfizer vaccine or first dose of the Johnson & Johnson vaccine? (If you don't know the exact date, please provide your best estimate)
Today M-D-Y
Months since vaccination:
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Individuals who are under 65 years old and have received 2 doses of the Pfizer or Moderna vaccines or 1 dose of the Johnson & Johnson vaccine in the last 6 months are not eligible at this time. Please visit combatcovid.hhs.gov for the most information about other trials and treatments.
Individuals who are under the age of 65 and have received the booster, 2 doses of the Pfizer or Moderna vaccines, or 1 dose of the Johnson & Johnson vaccine in the last 6 months are not eligible at this time. If you have other medical conditions or want to further discuss your eligibility, please call us at 651-661-9560. Please visit combatcovid.hhs.gov for the most information about other trials and treatments.
Individuals who are under the age of 65 and have received the booster, 2 doses of the Pfizer or Moderna vaccines, or 1 dose of the Johnson & Johnson vaccine are not eligible at this time. If you have other medical conditions or want to further discuss your eligibility, please call us at 651-661-9560. Please visit combatcovid.hhs.gov for the most information about other trials and treatments.
Did you test positive for the COVID-19 virus within the past 3 days?
* must provide value
yes
no
When did you test positive for Covid?
(Please enter the date on the day you tested positive for Covid or were confirmed to be positive for Covid)
* must provide value
Today M-D-Y
Please upload a picture or screenshot of your positive Covid test result here. If you are not able to provide proof of your positive Covid test via a picture or screenshot, please leave this form and call 651-661-9560 to speak with a research coordinator.
* must provide value
If you are uploading a picture of home test kit, please include your name and date in the picture of your results too. For all other test results, make sure the name, test results and date of test results are clearly visible
Have you tested positive for or been diagnosed with Covid-19 any other times in the past?
* must provide value
Yes
No
Are you between 30-85 years old?
* must provide value
yes
no
Are you between 76 and 85 years old?
* must provide value
Yes
No
Are you currently pregnant?
* must provide value
Yes
No
Please enter your date of birth:
Today M-D-Y
Age at time of screening:
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Do you have a GFR (Glomerular Filtration Rate) test result within the last 2 weeks?
* must provide value
Yes
No
Is your GFR > 45mL/min/1.73 m2?
* must provide value
Yes
No
Gender
* must provide value
Male Female Others
Are you pregnant?
* must provide value
Yes
No
Are you currently pregnant?
* must provide value
Yes
No
Please contact the study team at 651-661-9560 or
[email protected] to discuss eligibility for the branch of this trial for pregnant people.
What is your current height?
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What is your current weight(Ib)?
* must provide value
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Sorry you are not eligible
Are you of Asian or Latinx descent?
* must provide value
Yes
No
Sorry, you are not eligible for this study. Thank you for your interest! Please only fill out one form per individual.
Have you experienced any covid 19 symptoms?
* must provide value
yes
no
When did you symptoms begin?
* must provide value
Today M-D-Y
The duration of symptoms:
Has it been more than 7 days since your symptoms started?
* must provide value
yes
no
Are you currently pregnant?
* must provide value
Yes
No
Are you currently enrolled in any Covid related clinical trial?
* must provide value
yes
no
Have you already received any Covid treatments (i.e. monoclonal antibody infusion)?
* must provide value
yes
no
Do you have an email address and electronic device for communication?
* must provide value
Yes
No
Do you have a history of heart, liver, or kidney failure?
* must provide value
Yes
No
Are you currently taking any diabetes medications?
* must provide value
yes
no
Please which medication/s you receive for diabetes:
* must provide value
Are you currently hospitalized, for COVID-19 or other reasons
* must provide value
yes
no
Are you currently taking metformin?
* must provide value
yes
no
Are you currently taking fluvoxamine?
* must provide value
Yes
No
Are you currently taking ivermectin?
* must provide value
Yes
No
Are you currently on any of these medications? please check all that applies
* must provide value
cimetidine
hydroxychloroquine
dolutegravir
patiromer
ranolazine
tafenoquine
none
Are you currently taking any of these medications? Please select all that apply
* must provide value
Are you currently diagnosed as having stage 4 or 5 kidney disease:
* must provide value
yes
no
Are you currently diagnosed as having unstable liver disease ?
* must provide value
yes
no
Please describe:
* must provide value
Are you currently diagnosed as having an unstable heart failure?
* must provide value
yes
no
Please describe:
* must provide value
Do you currently have an Alcohol abuse disorder?
* must provide value
yes
no
When were you diagnosed as having alcohol abuse disorder?
* must provide value
Have you ever been hospitalized for lactic acidosis? (increase the build-up of lactic acids in the bloodstream)?
* must provide value
yes
no
Are you currently Immune-compromised (have had a solid organ transplant, bone marrow transplant, AIDS, on high dose steroids (>20mg/day).
* must provide value
yes
no
Are you willing and able to comply with the study procedures?
* must provide value
yes
no
Do you have any known medication allergies?
Yes
No
Are you currently diagnosed as having Bipolar disorder?
Yes
No
Have you ever been diagnosed with bipolar disorder or are you currently taking bipolar disorder medications (lithium or high-dose antipsychotics)?
Yes
No
Please provide additional details about your diagnosis or medications here. Once you have completed this form, please call 651-661-9560 to discuss eligibility.
Are you diagnosed with a current Loiasis infection, Loa loa infection, or Onchocerciasis infection?
Yes
No
Have you received a typhoid, BCG, or cholera vaccination in the last 14 days OR expect to receive one of these vaccinations in the next 3 days?
Yes
No
Are you currently taking any of these medications? Name, frequency, and dose of the medication :
Participant e-mail:
* must provide value
Phone number:
* must provide value
Today M-D-Y