Corona questionnaire
We ask you kindly to fill out this form before you sit down.
In the past 24 hours, have you experienced one or more of the following symptoms? *
1 point
Required
Do you share a home with somebody that right now is experiencing fever or cold sypmtoms? *
1 point
In the past 14 days, were you tested and diagnosed positive for the corona virus? *
1 point
Do you share a home with somebody that In the past 14 days, was tested and diagnosed positive for the corona virus? *
1 point
First and last name *
E-mail *
Phone number *
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