Step 3 Consuli Survey 1/5/2021

Email
example@example.com
Name
Step 3 of 3

Tell us more about yourself

Take a couple minutes to answer the questions below. Once you're done with this step, you'll be on the books to get SmartMatched™ with opportunities relevant to you. No information will be shared with any third party without your consent.
Location:*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number: *

Area CodePhone Number
Gender (changed to multiple choice property** hide this option**)*

FemaleMaleTransgender femaleTransgender maleTransgenderGenderqueer/Gender Non-ConformingQuestioningI prefer not to sayCustom
Select one or more options that reflect your gender*

FemaleMaleTransgender femaleTransgender maleTransgenderGenderqueer/Gender Non-ConformingQuestioningI prefer not to sayCustom
What sex were you assigned at birth?*

MaleFemaleIntersexPrefer not to answer
Birthdate:*

MonthDayYear
Ethnicity (Select all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteI prefer not to specifyOther
Please indicate your COVID-19 Diagnosis.*

Active DiagnosisPast DiagnosisNever Diagnosed
How many days have passed since your diagnosis?*
Days Since Diagnosis
Have you experienced covid-like symptoms and believe that you had / have COVID-19?

YesNo
Are you experiencing long-term COVID-19 symptoms?

YesNo
Have you experienced neurological symptoms for 3 or more months that caused you to be seen by a neurologist?

YesNo
How many months have you had symptoms for?
Months
Were you previously hospitalized due to COVID-19?*

YesNo
Have you ever received any of the following treatments for COVID-19 complications?*

Mechanical ventilationSupplemental oxygenNone of the above
Do you have a confirmed diagnosis of Sickle Cell disease?*

YesNo
Have you ever been diagnosed by a healthcare professional with any of the following medical conditions? (Select all that apply)*

Alzheimer's diseaseAsthmaChronic Respiratory DiseasesCirrhosisCrohn's DiseaseCOPDDementiaDiabetesHeart FailureHepatitis B or CHigh Blood PressureHIVKidney DiseaseLung CancerMultiple SclerosisUlcerative ColitisNone of the aboveOther
Have you ever been diagnosed by a healthcare professional with any of the following medical conditions? Select all that apply. Your answers are confidential.*

High blood pressure (hypertension)High cholesterolHeart diseaseStrokeDiabetes (Type 1 or Type 2)ObesityAsthmaChronic obstructive pulmonary disease (COPD)DepressionAnxiety disorderBipolar disorderPTSDEpilepsy or seizure disorderDementia or Alzheimer’s diseaseParkinson’s diseaseArthritis (e.g., osteoarthritis, rheumatoid arthritis)Chronic back painLupusMultiple sclerosisCrohn’s disease or ulcerative colitisCancer (any type)None of the abovePrefer not to sayOther
Are you currently pregnant or breastfeeding?*

YesNoNot applicable
Please indicate your occupation.*

Front-line healthcare workerOther type of healthcare providerCollege studentPrefer not to answerOther
Do you own a smartwatch?*

YesNo
Do you currently own or use any of the following smart wearable devices? (Select all that apply)

Apple WatchSamsung Galaxy WatchGarmin smartwatchGoogle Pixel WatchOura RingFitbitMiaoMiao Smart ReaderWHOOP bandBioStrapPrefer not to answerI do not own or use any smart wearable devicesOther
Do you have access to the internet?*

YesNo
Have you ever used 23andMe for DNA testing?*

YesNo
Would you like to consider participating in a clinical trial or study?*

YesNo
What types of studies would you like to get email alerts about?*

Vaccine trialsCOVID-19 treatment & recovery studiesData studiesOther studiesAll of the aboveNone
How did you hear about us?*
What platform did you hear about us on?*
Did you hear about us from a Patient Advocate? If so, please provide their name.
UniqueID
Should be Empty:

Step 3 of 3

Tell us more about yourself