Online COVID 19 (if you have had it) Interview Questionnaire Form

If you have had COVID 19- Questionnaire
Personal Information:
Full Name

First Name Middle Name Last Name
Age
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
E-mail
Questions and Details:
What does your medical doctor say about your risk of communicability?
What does your medical doctor say about getting physical activity?
What do you do in terms of activity?
Do you have any new (since your infection) skin marks, lesions, or rashes, especially on the toes, but anywhere on the body?
Do you have any new (since your infection) experience of severe deep muscle or joint pain - unrelated to recent physical activity?
Do you have any new (since your infection) discomfort with exertion?
Are you taking any drugs to manage blood clotting?
What other long-term consequences of your infection affect your life?
Should be Empty:

If you have had COVID 19- Questionnaire