|
PGP Participant Survey
|
Responses submitted 7/29/2011 12:40:52.
Show responses
|
| Timestamp |
7/29/2011 12:40:52 |
| Year of birth |
60-69 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 |
Female |
| Race/ethnicity |
White |
| Maternal grandmother: Country of origin |
Ireland |
| Paternal grandmother: Country of origin |
Ireland |
| Paternal grandfather: Country of origin |
Ireland |
| Maternal grandfather: Country of origin |
Ireland |
| Enrollment of relatives |
No |
| Enrollment of older individuals |
No |
| Enrollment of parents |
No |
| Have you uploaded genetic data to your PGP participant profile? |
Yes, I have uploaded 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? |
No, and I do not plan to |
| Blood sample |
Yes |
| Saliva sample |
Yes |
| Microbiome samples |
Yes |
| Tissue samples from surgery |
Yes |
| Tissue samples from autopsy |
Yes |
|
PGP Fall/Winter 2011 Saliva Kit: Large Tube Collection Survey
|
Responses submitted 10/20/2011 17:35:18.
Show responses
|
| Timestamp |
10/20/2011 17:35:18 |
| Which sample tube did you just collect? |
Big tube |
| How easy was this sample tube to use for collection? |
5 |
| Do you have any gum bleeding or gingivitis (gum inflammation)? |
No |
| Did you collect this sample all at once, or at multiple timepoints? |
All at once (in less than 5 minutes) |
| What time of day did you collect saliva? |
Very first thing in the morning, right after waking & before eating or drinking anything |
| Did you chew gum shortly before collection? |
No, no gum shortly before collection |
| When was the last time you brushed and/or flossed? |
6 - 12 hours before collection |
| Did you eat anything between the last time you brushed and/or flossed and the saliva collection? |
No, no eating between last brushing and collection |
| When was the last time you used mouthwash? |
More than 12 hours before collection |
| Did you eat anything between the last time you used mouthwash and the saliva collection? |
Not applicable: I rarely or never use mouthwash |
| If you have any specific comments regarding the sample you collected with this sample tube, please note them here. |
no problems |
|
PGP Fall/Winter 2011 Saliva Kit: Small Tube Collection Survey
|
Responses submitted 10/20/2011 17:36:08.
Show responses
|
| Timestamp |
10/20/2011 17:36:08 |
| Which sample tube did you just collect? |
Small tube |
| How easy was this sample tube to use for collection? |
5 |
| Do you have any gum bleeding or gingivitis (gum inflammation)? |
No |
| If you have any specific comments regarding the sample you collected with this sample tube, please note them here. |
none |
|
PGP Trait & Disease Survey 2012: Blood
|
Responses submitted 10/12/2012 7:29:13.
Show responses
|
| Timestamp |
10/12/2012 7:29:13 |
|
PGP Trait & Disease Survey 2012: Endocrine, Metabolic, Nutritional, and Immunity
|
Responses submitted 10/12/2012 7:30:13.
Show responses
|
| Timestamp |
10/12/2012 7:30:13 |
| Have you ever been diagnosed with any of the following conditions? |
Hypothyroidism, High cholesterol (hypercholesterolemia), Gout |
|
PGP Trait & Disease Survey 2012: Nervous System
|
Responses submitted 10/12/2012 7:31:25.
Show responses
|
| Timestamp |
10/12/2012 7:31:25 |
| Have you ever been diagnosed with one of the following conditions? |
Other peripheral neuropathy |
|
PGP Trait & Disease Survey 2012: Skin and Subcutaneous Tissue
|
Responses submitted 11/13/2012 22:00:47.
Show responses
|
| Timestamp |
11/13/2012 22:00:47 |
| Have you ever been diagnosed with any of the following conditions? |
Keloids, Hair loss (includes female and male pattern baldness) |
|
PGP Trait & Disease Survey 2012: Congenital Traits and Anomalies
|
Responses submitted 11/13/2012 22:01:41.
Show responses
|
| Timestamp |
11/13/2012 22:01:41 |
|
PGP Trait & Disease Survey 2012: Blood
|
Responses submitted 11/13/2012 22:02:20.
Show responses
|
| Timestamp |
11/13/2012 22:02:20 |
|
PGP Trait & Disease Survey 2012: Vision and hearing
|
Responses submitted 11/13/2012 22:03:39.
Show responses
|
| Timestamp |
11/13/2012 22:03:39 |
| Have you ever been diagnosed with one of the following conditions? |
Myopia (Nearsightedness), Astigmatism, Dry eye syndrome, Floaters |
|
PGP Trait & Disease Survey 2012: Nervous System
|
Responses submitted 11/13/2012 22:04:35.
Show responses
|
| Timestamp |
11/13/2012 22:04:35 |
|
PGP Trait & Disease Survey 2012: Cancers
|
Responses submitted 4/29/2013 0:18:32.
Show responses
|
| Timestamp |
4/29/2013 0:18:32 |
| Have you ever been diagnosed with one of the following conditions? |
Melanoma |
|
PGP Trait & Disease Survey 2012: Musculoskeletal System and Connective Tissue
|
Responses submitted 5/1/2014 22:59:50.
Show responses
|
| Timestamp |
5/1/2014 22:59:50 |
| Have you ever been diagnosed with any of the following conditions? |
Bone spurs |
| Other condition not listed here? |
long torso/extra vertebrae |
|
PGP Trait & Disease Survey 2012: Circulatory System
|
Responses submitted 5/1/2014 23:01:35.
Show responses
|
| Timestamp |
5/1/2014 23:01:35 |
| Have you ever been diagnosed with one of the following conditions? |
Hypertension |
| Other condition not listed here? |
swelling in ankles |
|
PGP Trait & Disease Survey 2012: Respiratory System
|
Responses submitted 5/1/2014 23:02:54.
Show responses
|
| Timestamp |
5/1/2014 23:02:54 |
| Have you ever been diagnosed with any of the following conditions? |
Deviated septum |
| Other condition not listed here? |
pnemonia repeats |
|
PGP Trait & Disease Survey 2012: Digestive System
|
Responses submitted 5/1/2014 23:04:32.
Show responses
|
| Timestamp |
5/1/2014 23:04:32 |
| Have you ever been diagnosed with any of the following conditions? |
Impacted tooth, Dental cavities, Gingivitis |
| Other condition not listed here? |
gall bladder flares |
|
PGP Trait & Disease Survey 2012: Genitourinary Systems
|
Responses submitted 5/1/2014 23:06:28.
Show responses
|
| Timestamp |
5/1/2014 23:06:28 |
| Have you ever been diagnosed with any of the following conditions? |
Urinary tract infection (UTI), Fibrocystic breast disease, Endometriosis, Ovarian cysts, Female infertility |
|
PGP Participant Survey
|
Responses submitted 8/29/2015 14:08:02.
Show responses
|
| Timestamp |
8/29/2015 14:08:02 |
| Year of birth |
1949 |
| Do you have a severe genetic disease or rare genetic trait? If so, you can add a description for your public profile. |
unknown |
| Sex/Gender |
Female |
| Race/ethnicity |
White |
| Maternal grandmother: Country of origin |
Ireland |
| Paternal grandmother: Country of origin |
Ireland |
| Paternal grandfather: Country of origin |
Ireland |
| Maternal grandfather: Country of origin |
Ireland |
| Month of birth |
October |
| Anatomical sex at birth |
Female |
| Maternal grandmother: Race/ethnicity |
White |
| Maternal grandfather: Race/ethnicity |
White |
| Paternal grandmother: Race/ethnicity |
White |
| Paternal grandfather: Race/ethnicity |
White |
|
PGP Basic Phenotypes Survey 2015
|
Responses submitted 9/10/2015 15:32:46.
Show responses
|
| Timestamp |
9/10/2015 15:32:46 |
| 1.1 — Blood Type |
B - |
| 1.2 — Height |
5'8" |
| 1.3 — Weight |
168 |
| 1.4 — Comments |
Thought I filled this out previously but it does not show up on site. |
| 2.1 — Left Eye (Photograph Number) (full-size image: https://goo.gl/XQ2Voh) |
10 |
| 2.2 — Right Eye (Photograph Number) (full-size image: https://goo.gl/XQ2Voh) |
10 |
| 2.3 — Left Eye Color - Text Description |
green, dark ring around flecks of gold |
| 2.4 — Right Eye Color - Text Description |
same |
| 2.5 —Comments |
usually one maternal family member in each generation has green
all those who do have some lymphatic system issues including self (eye and ankles failure to drain properly causing swelling/cystic) |
| 3.1 — What is your natural hair color currently, when without artificial color or dye? |
brown |
| 3.2 — Hair Color - Text Description |
brindled |
| 3.3 — Comments |
seem to have hit all colors over the years
born bald til 3 yrs old
white
blond
red
strawberry red
brownish red
darker brownish, brindled
even darker brownish
some white at temples only (@65yrs old) |
| 4.1 — Any final thoughts? |
would love to see or be able to easy access results when calculated with averages, etc, please? THANKS |
| 1.4 — Handedness |
Both equally well |
|
Harvard PGP: COVID-19 Demographics Survey
|
Responses submitted 3/24/2020 9:59:31.
Show responses
|
| Timestamp |
3/24/2020 9:59:31 |
| What is the zip code of your primary residence? |
80455 |
| Do have another residence where you spend more than 30 days a year? |
No |
| What is your age (in years)? |
70 |
| What is your gender? |
Female |
| Select all the following that apply to your current living arrangements. |
Live with partner/spouse, spouse has liver cncer being treated with Keytruda (6 mo) after radiation/chemo |
| What is your race? Pick all that apply. |
White, irish 98% |
| 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)] |
No |
| 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] |
Yes |
| 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? |
No |
| 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? |
Retired |
|
Harvard PGP: COVID-19 Health Assessment for Week of 22-28 March 2020
|
Responses submitted 3/24/2020 10:20:00.
Show responses
|
| Timestamp |
3/24/2020 10:20:00 |
| 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] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Headache] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Aches all over the body] |
Yes |
| 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] |
Unknown |
| 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] |
Yes |
| 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] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Vomiting] |
Yes |
| 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] |
Yes |
| 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] |
Yes |
| Are you currently experiencing any of the following symptoms? [Headache] |
Yes |
| Are you currently experiencing any of the following symptoms? [Aches all over the body] |
Yes |
| Are you currently experiencing any of the following symptoms? [Cough] |
No |
| Are you currently experiencing any of the following symptoms? [Rapid breathing] |
No |
| Are you currently experiencing any of the following symptoms? [Shortness of breath] |
Yes |
| 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] |
Yes |
| 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, take levoxyl low dose for thyroid and low dose lisinipril for high bp |
| 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? |
husband being treated for cancer does have high fevers but no other symptoms |
|
Harvard PGP: COVID-19 Health Assessment for Week of 29 March- 4 April 2020
|
Responses submitted 3/31/2020 11:23:07.
Show responses
|
| Timestamp |
3/31/2020 11:23:07 |
| 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] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Feeling cold, chills or shivers] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Headache] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Aches all over the body] |
Yes |
| 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] |
No |
| 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] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Vomiting] |
Yes |
| 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] |
Yes |
| Since Jan 1, 2020, have you experienced any of the following symptoms? [Pink eye (conjunctivitis)] |
Yes |
| 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] |
No |
| 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] |
Yes |
| 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 15:29:03.
Show responses
|
| Timestamp |
4/6/2020 15:29:03 |
| 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? |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Headache] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Aches all over the body] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Running nose] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Sore throat] |
Yes |
| 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. [Feeling cold, chills or shivers] |
Yes |
| In the past 2 weeks, which symptoms have you experienced. [Headache] |
Yes |
| In the past 2 weeks, which symptoms have you experienced. [Aches all over the body] |
Yes |
| In the past 2 weeks, which symptoms have you experienced. [Cough] |
Yes |
| 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 |
| 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] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Feeling cold, chills or shivers] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Headache] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Aches all over the body] |
Yes |
| 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. [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. [Vomiting] |
Yes |
| Are you regularly taking any of the following medications? Please choose all those that apply. |
None of these medications, took advil pm to sleep once; may now have seasonal allergy to spring? |
| 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)? |
not to my knowledge; go to U of CO Anshutz every 3 wks with husband for Keytruda treatment of his cancer |
|
Harvard PGP COVID-19 Health Assessment Week 4: 12 April - 18 April 2020
|
Responses submitted 4/13/2020 17:55:26.
Show responses
|
| Timestamp |
4/13/2020 17:55:26 |
| 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? |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Persistent high fever of 38°C (100.4°F) or higher, lasting for a day or more] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Feeling cold, chills or shivers] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Headache] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Aches all over the body] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Cough] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Rapid breathing] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Shortness of breath] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Wheezing or chest tightness] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Persistent pain or pressure in the chest] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Bluish lips or face] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Dizziness] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Confusion or inability to arouse] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Running nose] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Sore throat] |
Yes |
| Indicate which of the following symptoms you are currently experiencing. [Nausea] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Vomiting] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Abdominal Pain] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Diarrhea] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Pink eye (conjunctivitis)] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Loss of sense of smell] |
No |
| Indicate which of the following symptoms you are currently experiencing. [Loss of sense of taste] |
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] |
Yes |
| In the past 2 weeks, which symptoms have you experienced. [Aches all over the body] |
Yes |
| 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] |
No |
| 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] |
Yes |
| 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] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Feeling cold, chills or shivers] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Headache] |
Yes |
| Since Jan 1, 2020, to the best of your recollection which symptoms have you experienced. [Aches all over the body] |
Yes |
| 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] |
Yes |
| 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? |
may have some seasonal allergies symptoms-when snow melts in CO! |