Long-COVID Supplemental Survey

1
Please verify that you are human* This field is required.
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.Please be sure to enter the same email affiliated with your Consuli member account.
example@example.com
4
Mobile Phone Number* This field is required.
Please enter a valid phone number.
5
Have you tested positive for COVID-19?* This field is required.
YESNO
6
Have you experienced neurological symptoms for 3 or more months that caused you to be seen by a neurologist?* This field is required.
YESNO
7
Are you currently pregnant or breastfeeding?* This field is required.
Yes
No
Not Applicable
8
Are you willing to provide consent to the La Jolla Institute of Immunology to obtain and store your genetic data?* This field is required.
YESNO
9
Do you have a history of past infection with HIV, HBV, or HCV?* This field is required.
YESNO
10
Do you have any of the following types of anemia: Pernicious anemia, Aplastic anemia, Autoimmune hemolytic anemia, or Megaloblastic anemia?* This field is required.
YESNO
11
Do you have a history of significant cardiovascular disease or systemic diseases including, but not limited to, diabetes which is not controlled, renal disease, liver disease, malignancy, infection, or blood clotting disorder?* This field is required.
YESNO
12
If eligible, I am willing to enroll by:
September 30, 2022
I need a later date.
13
Are you willing to travel to San Diego, CA?
YESNO
14
How did you hear about this?* This field is required.
Consuli
Aila
Alice Perlowski
Angela Reiersen
Blooming Magnolia
Body Politic
Covid Care Group
Covid Wellness
Cynthia Adinig
Data Union
Dr. David Putrino
Dr. Mari Mitrani
Dr. Robi Tamargo
Elle Seibert
Long Covid Alliance
Maya McNulty
Mount Sinai
Mymee
Organicell
Pandemic Patients
Scripps Translational Research Institute
Shelby Hedgecock
Solve ME/CFS
Wail of a Tale
15
What platform did you hear about this on?* This field is required.
Clubhouse
Email
Facebook
Instagram
LinkedIn
Snapchat
Twitter
TikTok
YouTube
Other
16
Did you hear about us from a Patient Advocate? If so, please provide their name.
17
Thank you for your interest in participating in this Research Study. As your response indicates you have not tested positive for COVID-19, this particular study is not a match for you. (NOTE, you can go back to change your answer if your previous answer was simply an error.) And, as a member of Consuli you can sit back and relax knowing we'll continue to monitor opportunities and alert you to future offers matched to you.Please provide any feedback below.
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