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Covid questionnaire
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Email
*
Your email
Name
*
Your answer
Date of birth (XX/XX/XX)
*
Your answer
Are you or anyone in your household experiencing a cold or any flu-like symptoms including fever, cough, shortness of breath, nasal congestion, runny nose or sore throat?
*
Yes
No
Are you experiencing any nausea, vomiting or diarrhea?
*
Yes
No
If you answered yes to any of the above questions, please use the space below to explain.
Your answer
Please use the space below to explain. express any other pertinent information regarding COVID-19.
*
Your answer
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