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COVID-19 (Coronavirus) Questionnaire V 1.3

  1. 1. Are you 65 or older and been diagnosed with common COVID-19 comorbid conditions, such as: diabetes, obesity or high blood pressure?*

  2. 2. Have you been diagnosed with or tested positive for COVID-19?*

  3. 3. Have you been vaccinated against COVID-19?*

  4. Leave This Blank:

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