PGP Participant Survey
|
Responses submitted 7/16/2011 12:24:26.
Show responses
|
Timestamp |
7/16/2011 12:24:26 |
Year of birth |
21-29 years |
Which statement best describes you? |
I am comfortable making my genome sequence data publicly available without prior review. |
Severe disease or rare genetic trait |
No |
Sex/Gender |
Male |
Race/ethnicity |
White |
Maternal grandmother: Country of origin |
United States |
Paternal grandmother: Country of origin |
United States |
Paternal grandfather: Country of origin |
United States |
Maternal grandfather: Country of origin |
United States |
Enrollment of relatives |
Yes |
Enrollment of older individuals |
No |
Enrollment of parents |
Yes |
Enrolled relatives [Monozygotic / Identical twins] |
0 |
Enrolled relatives [Parents] |
0 |
Enrolled relatives [Siblings / Fraternal twins] |
1 |
Enrolled relatives [Children] |
0 |
Enrolled relatives [Grandparents] |
0 |
Enrolled relatives [Grandchildren] |
0 |
Enrolled relatives [Aunts/Uncles] |
0 |
Enrolled relatives [Nephews/Nieces] |
0 |
Enrolled relatives [Half-siblings] |
0 |
Enrolled relatives [Cousins or more distant] |
0 |
Enrolled relatives [Not genetically related (e.g. husband/wife)] |
0 |
Are all your enrolled relatives linked to your PGP profile? |
Yes |
Have you uploaded genetic data to your PGP participant profile? |
No, I have no genetic data. |
Have you used the PGP web interface to record a designated proxy? |
Yes |
Have you uploaded health record data using our Google Health or Microsoft Healthvault interfaces? |
Yes |
Uploaded health records: Update status |
Yes |
Uploaded health records: Extensiveness |
5 |
Blood sample |
Yes |
Saliva sample |
Yes |
Microbiome samples |
Yes |
Tissue samples from surgery |
Yes |
Tissue samples from autopsy |
Yes |
PGP Participant Survey
|
Responses submitted 2/15/2012 12:51:15.
Show responses
|
Timestamp |
2/15/2012 12:51:15 |
Year of birth |
21-29 years |
Which statement best describes you? |
I am comfortable making my genome sequence data publicly available without prior review. |
Severe disease or rare genetic trait |
No |
Sex/Gender |
Male |
Race/ethnicity |
White |
Maternal grandmother: Country of origin |
Other / don't know / no response |
Paternal grandmother: Country of origin |
Russian Federation |
Paternal grandfather: Country of origin |
Poland |
Maternal grandfather: Country of origin |
Other / don't know / no response |
Enrollment of relatives |
Yes |
Enrollment of older individuals |
No |
Enrollment of parents |
Yes |
Enrolled relatives [Monozygotic / Identical twins] |
0 |
Enrolled relatives [Parents] |
0 |
Enrolled relatives [Siblings / Fraternal twins] |
1 |
Enrolled relatives [Children] |
0 |
Enrolled relatives [Grandparents] |
0 |
Enrolled relatives [Grandchildren] |
0 |
Enrolled relatives [Aunts/Uncles] |
0 |
Enrolled relatives [Nephews/Nieces] |
0 |
Enrolled relatives [Half-siblings] |
0 |
Enrolled relatives [Cousins or more distant] |
0 |
Enrolled relatives [Not genetically related (e.g. husband/wife)] |
0 |
Are all your enrolled relatives linked to your PGP profile? |
Yes |
Have you uploaded genetic data to your PGP participant profile? |
No, I have no genetic data. |
Have you uploaded health record data using our Google Health or Microsoft Healthvault interfaces? |
Yes |
Uploaded health records: Update status |
Yes |
Uploaded health records: Extensiveness |
5 |
Blood sample |
Yes |
Saliva sample |
Yes |
Microbiome samples |
Yes |
Tissue samples from surgery |
Yes |
Tissue samples from autopsy |
Yes |
PGP Participant Survey
|
Responses submitted 5/15/2012 16:48:27.
Show responses
|
Timestamp |
5/15/2012 16:48:27 |
Year of birth |
21-29 years |
Which statement best describes you? |
I am comfortable making my genome sequence data publicly available without prior review. |
Severe disease or rare genetic trait |
No |
Sex/Gender |
Male |
Race/ethnicity |
White |
Maternal grandmother: Country of origin |
Other / don't know / no response |
Paternal grandmother: Country of origin |
Russian Federation |
Paternal grandfather: Country of origin |
Poland |
Maternal grandfather: Country of origin |
Other / don't know / no response |
Enrollment of relatives |
Yes |
Enrollment of older individuals |
No |
Enrollment of parents |
Yes |
Enrolled relatives [Siblings / Fraternal twins] |
1 |
Are all your enrolled relatives linked to your PGP profile? |
Yes |
Have you uploaded genetic data to your PGP participant profile? |
No, I have no genetic data. |
Have you used the PGP web interface to record a designated proxy? |
Yes |
Have you uploaded health record data using our Google Health or Microsoft Healthvault interfaces? |
Yes |
Uploaded health records: Update status |
Yes |
Uploaded health records: Extensiveness |
5 |
Blood sample |
Yes |
Saliva sample |
Yes |
Microbiome samples |
Yes |
Tissue samples from surgery |
Yes |
Tissue samples from autopsy |
Yes |
PGP Trait & Disease Survey 2012: Cancers
|
Responses submitted 12/18/2012 22:32:11.
Show responses
|
Timestamp |
12/18/2012 22:32:11 |
PGP Trait & Disease Survey 2012: Endocrine, Metabolic, Nutritional, and Immunity
|
Responses submitted 12/18/2012 22:32:52.
Show responses
|
Timestamp |
12/18/2012 22:32:52 |
Have you ever been diagnosed with any of the following conditions? |
Lactose intolerance |
PGP Trait & Disease Survey 2012: Blood
|
Responses submitted 12/18/2012 22:33:13.
Show responses
|
Timestamp |
12/18/2012 22:33:13 |
PGP Trait & Disease Survey 2012: Nervous System
|
Responses submitted 12/18/2012 22:33:53.
Show responses
|
Timestamp |
12/18/2012 22:33:53 |
Have you ever been diagnosed with one of the following conditions? |
Essential tremor |
PGP Trait & Disease Survey 2012: Vision and hearing
|
Responses submitted 12/18/2012 22:34:17.
Show responses
|
Timestamp |
12/18/2012 22:34:17 |
Have you ever been diagnosed with one of the following conditions? |
Myopia (Nearsightedness), Astigmatism, Floaters |
PGP Trait & Disease Survey 2012: Circulatory System
|
Responses submitted 12/18/2012 22:34:53.
Show responses
|
Timestamp |
12/18/2012 22:34:53 |
Have you ever been diagnosed with one of the following conditions? |
Hemorrhoids |
PGP Trait & Disease Survey 2012: Respiratory System
|
Responses submitted 12/18/2012 22:35:11.
Show responses
|
Timestamp |
12/18/2012 22:35:11 |
Have you ever been diagnosed with any of the following conditions? |
Asthma |
PGP Trait & Disease Survey 2012: Digestive System
|
Responses submitted 12/18/2012 22:35:35.
Show responses
|
Timestamp |
12/18/2012 22:35:35 |
Have you ever been diagnosed with any of the following conditions? |
Temporomandibular joint (TMJ) disorder |
PGP Trait & Disease Survey 2012: Genitourinary Systems
|
Responses submitted 12/18/2012 22:35:52.
Show responses
|
Timestamp |
12/18/2012 22:35:52 |
PGP Trait & Disease Survey 2012: Skin and Subcutaneous Tissue
|
Responses submitted 12/18/2012 22:36:16.
Show responses
|
Timestamp |
12/18/2012 22:36:16 |
Have you ever been diagnosed with any of the following conditions? |
Eczema, Hair loss (includes female and male pattern baldness) |
PGP Trait & Disease Survey 2012: Musculoskeletal System and Connective Tissue
|
Responses submitted 12/18/2012 22:36:32.
Show responses
|
Timestamp |
12/18/2012 22:36:32 |
PGP Trait & Disease Survey 2012: Congenital Traits and Anomalies
|
Responses submitted 12/18/2012 22:36:54.
Show responses
|
Timestamp |
12/18/2012 22:36:54 |
Harvard PGP: COVID-19 Demographics Survey
|
Responses submitted 3/23/2020 18:50:03.
Show responses
|
Timestamp |
3/23/2020 18:50:03 |
What is the zip code of your primary residence? |
94702 |
Do have another residence where you spend more than 30 days a year? |
No |
What is your age (in years)? |
35 |
What is your gender? |
Male |
Select all the following that apply to your current living arrangements. |
Live with partner/spouse, Live with child/children under age 18 |
What is your race? Pick all that apply. |
White |
What is your ethnicity? |
Not Hispanic or Latino or Spanish Origin |
Select which one of the following applies to you and your birth status. |
None of the above |
Have you ever been diagnosed with any of the following? [Asthma (Adult)] |
No |
Have you ever been diagnosed with any of the following? [Asthma (Childhood)] |
Yes |
Have you ever been diagnosed with any of the following? [Chronic obstructive pulmonary disease (COPD)] |
No |
Have you ever been diagnosed with any of the following? [Emphysema] |
No |
Have you ever been diagnosed with any of the following? [Chronic bronchitis] |
No |
Have you ever been diagnosed with any of the following? [Pneumonia] |
No |
Have you ever been diagnosed with any of the following? [Type 1 Diabetes] |
No |
Have you ever been diagnosed with any of the following? [Type 2 Diabetes] |
No |
Have you ever smoked tobacco products? |
Prefer not to answer |
Have you ever used e-cigarettes (e.g. JUUL, Vuse, MarkTen)? |
No |
Which one of the following best describes your employment status for the past 3 months? |
Employed: Working 40 or more hrs per week |
Select the category that best describes your occupation. |
Management |
What is the zip code of your primary workplace/worksite? |
94702 |
Do you have a secondary workplace/worksite where you work more than 30 days a year? |
No |
If a vaccine against coronovirus (COVID-19) would reach the stage where it must be tested for safety and efficacy in humans, would you - assuming that you are eligible - be interested in taking part in that trial? |
Yes |
Harvard PGP: COVID-19 Health Assessment for Week of 22-28 March 2020
|
Responses submitted 3/23/2020 19:21:57.
Show responses
|
Timestamp |
3/23/2020 19:21:57 |
Since Jan 1, 2020, have you been ill with a cold or flu-like illness? |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Feeling cold, chills or shivers] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Headache] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Aches all over the body] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Cough] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Rapid breathing] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Shortness of breath] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Wheezing or chest tightness] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Persistent pain or pressure in the chest] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Bluish lips or face] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Dizziness] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Confusion or inability to arouse] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Running nose] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Sore throat] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Nausea] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Vomiting] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Abdominal pain] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Diarrhea] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Pink eye (conjunctivitis)] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Loss of sense of smell] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Loss of sense of taste] |
No |
Are you currently experiencing any of the following symptoms? [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Are you currently experiencing any of the following symptoms? [Feeling cold, chills or shivers] |
No |
Are you currently experiencing any of the following symptoms? [Headache] |
No |
Are you currently experiencing any of the following symptoms? [Aches all over the body] |
No |
Are you currently experiencing any of the following symptoms? [Cough] |
Yes |
Are you currently experiencing any of the following symptoms? [Rapid breathing] |
No |
Are you currently experiencing any of the following symptoms? [Shortness of breath] |
No |
Are you currently experiencing any of the following symptoms? [Wheezing or chest tightness] |
Yes |
Are you currently experiencing any of the following symptoms? [Persistent pain or pressure in the chest] |
No |
Are you currently experiencing any of the following symptoms? [Bluish lips or face] |
No |
Are you currently experiencing any of the following symptoms? [Dizziness] |
No |
Are you currently experiencing any of the following symptoms? [Confusion or inability to arouse] |
No |
Are you currently experiencing any of the following symptoms? [Running nose] |
No |
Are you currently experiencing any of the following symptoms? [Sore throat] |
Yes |
Are you currently experiencing any of the following symptoms? [Nausea] |
No |
Are you currently experiencing any of the following symptoms? [Vomiting] |
No |
Are you currently experiencing any of the following symptoms? [Abdominal Pain] |
No |
Are you currently experiencing any of the following symptoms? [Diarrhea] |
No |
Are you currently experiencing any of the following symptoms? [Pink eye (conjunctivitis)] |
No |
Are you currently experiencing any of the following symptoms? [Loss of sense of smell] |
No |
Are you currently experiencing any of the following symptoms? [Loss of sense of taste] |
No |
Are you regularly taking any of the following medications? Please choose all those that apply. |
None of these medications |
Have you been tested for coronavirus (COVID-19) by a medical doctor or other official testing service? |
No, I have not tried to get tested |
In the past 4 weeks, have you been in close contact with a person who has tested positive for coronavirus (COVID-19)? |
No |
In the past 4 weeks, have you been in close contact with a person who has symptoms consistent with coronavirus (COVID-19) but has not been tested? |
No |
Harvard PGP: COVID-19 Health Assessment for Week of 29 March- 4 April 2020
|
Responses submitted 3/30/2020 11:45:24.
Show responses
|
Timestamp |
3/30/2020 11:45:24 |
Since Jan 1, 2020, have you been ill with a cold or flu-like illness? |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Feeling cold, chills or shivers] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Headache] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Aches all over the body] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Cough] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Rapid breathing] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Shortness of breath] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Wheezing or chest tightness] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Persistent pain or pressure in the chest] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Bluish lips or face] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Dizziness] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Confusion or inability to arouse] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Running nose] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Sore throat] |
Yes |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Nausea] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Vomiting] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Abdominal pain] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Diarrhea] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Pink eye (conjunctivitis)] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Loss of sense of smell] |
No |
Since Jan 1, 2020, have you experienced any of the following symptoms? [Loss of sense of taste] |
No |
Are you currently experiencing any of the following symptoms? [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Are you currently experiencing any of the following symptoms? [Feeling cold, chills or shivers] |
No |
Are you currently experiencing any of the following symptoms? [Headache] |
No |
Are you currently experiencing any of the following symptoms? [Aches all over the body] |
No |
Are you currently experiencing any of the following symptoms? [Cough] |
Yes |
Are you currently experiencing any of the following symptoms? [Rapid breathing] |
No |
Are you currently experiencing any of the following symptoms? [Shortness of breath] |
No |
Are you currently experiencing any of the following symptoms? [Wheezing or chest tightness] |
No |
Are you currently experiencing any of the following symptoms? [Persistent pain or pressure in the chest] |
No |
Are you currently experiencing any of the following symptoms? [Bluish lips or face] |
No |
Are you currently experiencing any of the following symptoms? [Dizziness] |
No |
Are you currently experiencing any of the following symptoms? [Confusion or inability to arouse] |
No |
Are you currently experiencing any of the following symptoms? [Running nose] |
No |
Are you currently experiencing any of the following symptoms? [Sore throat] |
Yes |
Are you currently experiencing any of the following symptoms? [Nausea] |
No |
Are you currently experiencing any of the following symptoms? [Vomiting] |
No |
Are you currently experiencing any of the following symptoms? [Abdominal Pain] |
No |
Are you currently experiencing any of the following symptoms? [Diarrhea] |
No |
Are you currently experiencing any of the following symptoms? [Pink eye (conjunctivitis)] |
No |
Are you currently experiencing any of the following symptoms? [Loss of sense of smell] |
No |
Are you currently experiencing any of the following symptoms? [Loss of sense of taste] |
No |
Are you regularly taking any of the following medications? Please choose all those that apply. |
None of these medications |
Have you been tested for coronavirus (COVID-19) by a medical doctor or other official testing service? |
No, I have not tried to get tested |
In the past 4 weeks, have you been in close contact with a person who has tested positive for coronavirus (COVID-19)? |
No |
In the past 4 weeks, have you been in close contact with a person who has symptoms consistent with coronavirus (COVID-19) but has not been tested? |
No |
Harvard PGP: COVID-19 Health Assessment for Week of 5 April - 11 April 2020
|
Responses submitted 4/6/2020 14:08:42.
Show responses
|
Timestamp |
4/6/2020 14:08:42 |
Since Jan 1, 2020, have you been ill with a cold or flu-like illness? |
Yes |
Currently are you experiencing ANY of the above list of symptoms? |
No |
In the past two weeks, have you experienced ANY of the above list of symptoms? |
Yes |
In the past 2 weeks, which symptoms have you experienced. [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
In the past 2 weeks, which symptoms have you experienced. [Feeling cold, chills or shivers] |
No |
In the past 2 weeks, which symptoms have you experienced. [Headache] |
No |
In the past 2 weeks, which symptoms have you experienced. [Aches all over the body] |
No |
In the past 2 weeks, which symptoms have you experienced. [Cough] |
Yes |
In the past 2 weeks, which symptoms have you experienced. [Rapid breathing] |
No |
In the past 2 weeks, which symptoms have you experienced. [Shortness of breath] |
No |
In the past 2 weeks, which symptoms have you experienced. [Wheezing or chest tightness] |
No |
In the past 2 weeks, which symptoms have you experienced. [Persistent pain or pressure in the chest] |
No |
In the past 2 weeks, which symptoms have you experienced. [Bluish lips or face] |
No |
In the past 2 weeks, which symptoms have you experienced. [Dizziness] |
No |
In the past 2 weeks, which symptoms have you experienced. [Confusion or inability to arouse] |
No |
In the past 2 weeks, which symptoms have you experienced. [Running nose] |
Yes |
In the past 2 weeks, which symptoms have you experienced. [Sore throat] |
Yes |
In the past 2 weeks, which symptoms have you experienced. [Nausea] |
No |
In the past 2 weeks, which symptoms have you experienced. [Vomiting] |
No |
In the past 2 weeks, which symptoms have you experienced. [Abdominal pain] |
No |
In the past 2 weeks, which symptoms have you experienced. [Diarrhea] |
No |
In the past 2 weeks, which symptoms have you experienced. [Pink eye (conjunctivitis)] |
No |
In the past 2 weeks, which symptoms have you experienced. [Loss of sense of smell] |
No |
In the past 2 weeks, which symptoms have you experienced. [Loss of sense of taste] |
No |
Since Jan 1, 2020, to the best of your recollection,have you experienced ANY of the above list of symptoms? |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Feeling cold, chills or shivers] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Headache] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Aches all over the body] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Cough] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Rapid breathing] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Shortness of breath] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Wheezing or chest tightness] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Persistent pain or pressure in the chest] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Bluish lips or face] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Dizziness] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Confusion or inability to arouse] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Running nose] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Sore throat] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Nausea] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Vomiting] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Abdominal pain] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Diarrhea] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Pink eye (conjunctivitis)] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Loss of sense of smell] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Loss of sense of taste] |
No |
Are you regularly taking any of the following medications? Please choose all those that apply. |
None of these medications |
Have you been tested for coronavirus (COVID-19) by a medical doctor or other official testing service? |
No, I have not tried to get tested |
In the past 4 weeks, have you been in close contact with a person who has tested positive for coronavirus (COVID-19)? |
No |
In the past 4 weeks, have you been in close contact with a person who has symptoms consistent with coronavirus (COVID-19) but has not been tested? |
No |
Harvard PGP COVID-19 Health Assessment Week 4: 12 April - 18 April 2020
|
Responses submitted 4/13/2020 18:25:21.
Show responses
|
Timestamp |
4/13/2020 18:25:21 |
Are you currently ill with a cold or flu-like illness? |
No |
Since Jan 1, 2020, have you been ill with a cold or flu-like illness? |
Yes |
Currently are you experiencing ANY of the above list of symptoms? |
No |
In the past two weeks, have you experienced ANY of the above list of symptoms? |
No |
Since Jan 1, 2020, to the best of your recollection,have you experienced ANY of the above list of symptoms? |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Feeling cold, chills or shivers] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Headache] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Aches all over the body] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Cough] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Rapid breathing] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Shortness of breath] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Wheezing or chest tightness] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Persistent pain or pressure in the chest] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Bluish lips or face] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Dizziness] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Confusion or inability to arouse] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Running nose] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Sore throat] |
Yes |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Nausea] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Vomiting] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Abdominal pain] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Diarrhea] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Pink eye (conjunctivitis)] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Loss of sense of smell] |
No |
Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Loss of sense of taste] |
No |
Are you regularly taking any of the following medications? Please choose all those that apply. |
None of these medications |
Have you been tested for coronavirus (COVID-19) by a medical doctor or other official testing service? |
No, I have not tried to get tested |
In the past 4 weeks, have you been in close contact with a person who has tested positive for coronavirus (COVID-19)? |
No |
In the past 4 weeks, have you been in close contact with a person who has symptoms consistent with coronavirus (COVID-19) but has not been tested? |
No |