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COVID-19 (Coronavirus) Questionnaire

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  9. 1a. Are you 65 or older and been diagnosed with common COVID-19 comorbid conditions, such as: diabetes, obesity or high blood pressure?*
  11. 1b. Have you been fully vaccinated against COVID-19?
  13. 2. Have you traveled outside of the USA in the last 14 days?*
  15. 3. Have you traveled within the USA in the last 14 days?*
  17. 4. Have you been on a cruise ship in the last 14 days?*
  19. 5. Has a household member been in close contact with anyone who has traveled domestically or internationally in the last 14 days?*
  21. 6. Have you attended any events or gatherings with more than 100 people?*
  23. 7. Have you been in close contact with a person known to have the 2019 Novel Coronavirus?*
  25. 8. Have you and/or a household member been asked to self-quarantine?*
  27. 9. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?*
    28. Leave This Blank:

  30. This field is not part of the form submission.