Lostisland COVID-19 Questionnarie
Dear citizens,
As the COVID-19 pandemic continues ravaging the world, we're trying to keep track of how many Lostislandians contracted the disease and if we could be of any help.
Lostisland as an organization isn't authorized to demand medical information, filling this in is 100% voluntary. But if you're a Lostislandic citizen who tested positive for COVID-19 and would like to get support or share your experience with other citizens, we invite you to fill in this form.
* Required
Email address
*
Your email
Citizen Name
*
Your answer
Date Developed Sympthoms
*
MM
/
DD
/
YYYY
Date COVID-19 Confirmed
*
MM
/
DD
/
YYYY
Date Hospitalized (if applicable)
*
MM
/
DD
/
YYYY
Date Discharged from Hospital (if applicable)
*
MM
/
DD
/
YYYY
Date Tested Negative (if applicable)
*
MM
/
DD
/
YYYY
What is your current condition?
*
Choose
Confirmed Recovered
No Sympthoms
Mild Sympthoms
Moderate Sympthoms
Severe Sympthoms
Under Ventilator
Would you be willing to share your story with other Lostislandic citizens?
*
Yes
No
Anything else you'd like to add?
Your answer
Send me a copy of my responses.
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