CoVID-19 Treatment with Chlorpheniramine maleate (formerly available as Chlor-Trimeton), a Retrospective Study

General Information

Shaun D. Black, PhD wishes to thank you for completing this survey on your experience with Chlorpheniramine maleate. Your feedback will help him publish his work on this vital over-the-counter drug and make this knowledge more widely available. Your information will be kept strictly confidential; only statistical summaries will ever appear in print. Your participation is entirely voluntary and completion of the survey indicates your consent to participate.

If you would rather not complete this on-line questionnaire, please contact Dr. Black at 903-581-7539 or sblack@uttyler.edu to arrange for a paper survey or a personal interview.

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* 1. Demographic information

First Name

Last Name

City

State

Age

Gender (M/F)

Race

E-mail Address

Phone Number

Number of People in Household

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* 2. Please say how you took Chlorpheniramine (choose one option that best describes your situation)

I took Chlorpheniramine preventively

I took Chlorpheniramine preventively and continued after exposure to CoVID-19

I took Chlorpheniramine preventively and continued after I contracted CoVID-19

I took Chlorpheniramine after exposure to CoVID-19

I took Chlorpheniramine after I was mildly ill with CoVID-19

I took Chlorpheniramine after I was moderately ill with CoVID-19

I took Chlorpheniramine after I was severely ill with CoVID-19

I never took Chlorpheniramine (then, skip to Question 15)

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* 3. What dose of Chlorpheniramine did you take? (please select only one)

1 tablet (4 mg) once per day

1 tablet (4 mg) twice per day

1 tablet (4 mg) 3 times per day

1 tablet (4 mg) 4 times per day

1 tablet (8 mg) once per day

1 tablet (8 mg) twice per day

Other (please specify)

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* 4. Date of known exposure to the CoVID-19 Coronavirus? (please leave blank if unknown)

Date (mo/day/yr)

Date

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* 5. Date of your CoVID-19 viral antigen test (PCR or other; please leave blank if not tested)

Date (mo/day/yr)

Date

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* 6. Supplements, vitamins, and prescriptions you take

Calcium supplement

Fish or Krill oil (Omega-3 fatty acid) supplement

Magnesium supplement

Multivitamin supplement

Probiotic supplement

Vitamin C (ascorbic acid) supplement

Vitamin D supplement

Vitamin E supplement

Zinc supplement

Rx Albuterol (Accuneb, Ventolin, Proair, Proventil), used to treat and prevent bronchospasm, e.g. in asthma

Rx Amlodipine (Norvasc, Amvaz), used to treat high blood-pressure

Rx Azithromycin (Z-Pack, Zithromax) antibiotic

Rx Brompheniramine Maleate; Dextromethorphan Hydrobromide; Pseudoephedrine Hydrochloride, an antihistamine, decongestant

Rx Hydrocodone / Acetaminophen (Zolvit, Lorcet, Vicodin, Hycet, Xodol, Norco, Lortab, Maxidone), used to treat deep pain

Rx Lisinopril (Prinivil, Zestril), an ACE inhibitor used to treat high blood pressure

Rx Losartan (Cozaar), used to treat high blood-pressure and kidney disease

Rx Montelukast (Singulair), used to treat asthma

Other supplements, vitamins, and prescriptions you take (please specify)

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* 7. Results of your CoVID-19 test? (please leave blank if inapplicable)

Positive

Negative

Inconclusive

Other (please specify)

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* 8. When did you become ill with CoVID-19 and begin to experience symptoms? (please leave blank if inapplicable)

Date (mo/day/yr)

Date

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* 9. Which symptoms did you experience when you were ill with CoVID-19? (select all appropriate)

fever

chills

cough

shortness of breath

difficulty breathing

fatigue

muscle/body ache

loss of taste or smell

sore throat

congestion (runny nose)

nausea

vomiting

diarrhea

none of the above

Other (please specify)

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* 10. How ill did you become after you contracted CoVID-19?

0 (no symptoms)

100 (gravely ill)

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. Were you hospitalized?

Yes

Date if known and details during hospitalization

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* 12. Your co-morbidities or conditions (please check all applicable chronic conditions)

asthma

cancer

congestive obstructive pulmonary disease (COPD)

diabetes

Down's Syndrome

heart disease (hypertension, cardiomyopathy, etc.)

kidney disease

sickle-cell disease

smoking

obesity

pregnancy

none of the above

Other (please specify)

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* 13. How many days were you ill with CoVID-19?

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* 14. How much do you believe that Chlorpheniramine helped during your CoVID-19 disease?

No effect

Curative

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 15. Please provide any other information or feedback that you feel would be helpful to this retrospective study

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* 16. Thank you so much for contributing your information and feedback. Dr. Black truly appreciates your time and thoughtfulness! If you have any other comments, please note them below . . .