Coronavirus Survivors Questionnaire
Please help everyone stay safe by sharing your stories of "How I Got Covid19". If you are a Coronavirus-19 survivor, you have the ANSWERS of how you got infected! an easy way to help our world with this battle, is to fill out the form now and let's save lives!
Note: The information in this study will be used only for research purposes and in ways that will not reveal who you are. We will sort the data to determine the highest risks. You will not be identified in any publication from this study. We and the World thank you for Sharing Your Lessons and Saving So Many Lives
Are you answering? You can do this survey anomalously if you don't want to disclose your name :)
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Myself
Someone else
Do you know how you/they got infected?
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Yes - 100%
Maybe
No
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How did you get infected? Remember this survey is anonymous
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Congested commute: flight, train, long bus trip
Large gathering: meetings, church, movies etc
Personal contact: social visits
Hospital: short-term or long-term stay
Touching an object: door handles, food, boxes, etc. (same like)
Other
If congested commute, was it a
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Short exposure like less than 5mins
Medium exposure 1-3 hours
Long exposure more than 3 hours
Other
Event exposure,
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An airplane/train/ long bus trip /cruise ship
Taxi/short bus trip
Conference/church meeting/ stadium event
Shopping Mall/ school/ univeristy
Other
If personal contact, was it because of?
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a shared accommodation eg: spouse/ roommate
a one-time event like dinner for 2 or 3
handshake
a hug for a less than 10 seconds
a hug for a more than 10 seconds
from a taxi driver that handed you your bags?
the taxi did not have divider separating you?
the taxi drive handed your money?
someone coughed on me
a direct kiss
Other
Hospital
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Doctors visit/check-up/day care
less than one week in hospital prior to infection
long term stay - Nursing Homes
Touching an object, door handle, food, boxes, etc. (same like)
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Coffee or food drive-through
Groceries, postal-parcel/pizza delivery
Door handles/ handrail/ elevators buttons
Money or credit card
Other
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(Multiple Answers are ok) were you using any of these precautions when you got infected?
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A face mask
Alcohol bases sanitizers to wash hands/surfaces
Social distancing
Rubber gloves
Other
Using a face mask, what type?
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Regular
N-95 mask
Cloth
Heavy duty respirator
Using alcohol bases sanitizers to wash hands/surfaces . What percentage?
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70% Isopropyl or Ethyl
Below 70% Isopropyl or Ethyl Alcohol
Did you practise social distancing and hand washing. (Multiple Answers are ok)
less than 1 meter/3ft
more than 1 meter/3ft
washed hands 3X's a day
washed hands 20X's a day
none
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Did you have any of the following symptoms? (Multiple Answers are ok)
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Fever; high grade
Fever; low grade
Cough; mild
Cough: deep
Sneezing
Shortness of breath
Persistent pain or pressure in the chest
Muscle aches
Sore throat
Unexplained loss of taste or smell
Headache
Bluish lips or face
Diarrhea
Other
Did you have any pre-existing medical conditions?
Asthma
Diabetic
Heart disease
Over weight
Hypertension
Other
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Did you have a hard time getting tested in a timely matter?
I was tested immediatley
I had to go back to my doctor or clinic a 2nd time
It was almost impossible to get tested
I never did get tested, my diagnosis was based on symptoms only.
How long were you symptomactic before your diagnosis?
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24 Hours
1-3 Days
3-5 days
6-12 days
Other
Did you travel from December to present?
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Overseas
Local
No travel history
What Country?
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What City?
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How do you think you caught your infection?
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Immediate Family (spouse and children)
Extended Family (grandparents, uncle, aunties, nephews and nieces)
Friends and other colleagues
Community: shopping, passenger sitting beside you etc
Other
If community, please explain more details,
Did you have a mild or extreme case of Covid-19?
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Mild
Extreme
Other
If you have recovered, how do you feel now?
Back to full health
Mild lung congestion (scarring)
Regular or tolerable pain
Extreme pain
Other
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What advice do you have to prevent an infection?
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What is your message to all the front-liners like Doctors and Nurses?
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What country are you in?
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Country NOT on List
Canada
United States
United States - NY
United States - CA
United States - WA
Europe
Italy
France
United Kingdom
Spain
Germany
Australia
Hong Kong
South Korea
Japan
China
Another Country not on the list above:
What is your age range?
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Under 15
16 - 30
31 - 50
51 - 70
71 plus
What is your gender?
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Male
Female
Thanks so much for all these great clues so we can all learn and be safer. You probably have saved lives :)
Yes, you give us permission to contct you for a follow-up or to offer you some support!
No, you want to stay anonymous ... np, we do really thank you for your help!
Name (Optional) Yes, you can do this survey anonymously, but we sure would appreciate your name in which we kept private
First Name
Last Name
Email (Optional) but boy we love to ask you more questions or even an interview if you have critical information.
example@example.com your contact information will NEVER be shared with anyone and we will only message you if we have critical questions?
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