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COVID Questionnaire
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Step
1
of 4
Is this your first time or a follow up?
*
First time
Follow up
Next
Name
*
First
Last
Email
*
Next
What medical conditions do you have? Select all that apply to you.
*
Diabetes
Neurologic problems - including history of stroke or mini-stroke
Chronic kidney disease or kidney failure
Lung problems - Asthma, COPD, emphysema
Cancer - currently receiving treatment for cancer
Liver disease
Heart disease or heart failure
High blood pressure
Pregnant
Immune system disorders, receiving chemotherapy, steroids or other immunosuppressive, History of HIV
None apply
Next
Are you interested in a medical evaluation?
*
Yes
No
Submit