Coronavirus And Underlying Health Conditions

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We're looking to hear from people with chronic conditions about whether the pandemic affected their health. How have you been impacted? Fill out the form below and let us know, and we may contact you for a future story.

Name *

Email *

Phone Number

Race/Ethnicity *

White

Black/African-American

Hispanic/Latino/Latinx

American Indian or Alaskan Native

Asian/Pacific Islander

Other

Required

Did you have a chronic health condition prior to the COVID-19 pandemic? If yes, explain.

Was your health care disrupted by the pandemic? If yes, explain how.

Has your health worsened at any point since the pandemic began? If yes, explain.

Would you be willing to speak with a reporter and potentially be interviewed for radio broadcast? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.