Surveypoint

Q1

Are you currently experiencing any symptoms?

High fever

Cough

Difficulty in breathing

Persistent pain or pressure in the chest

Body aches

Nasal congestion

Runny nose

Sore throat

Diarrhea

None

Q2

Please select your age group

0 - 10

11 - 19

20 - 44

45 - 64

65 - 74

75 - 90

90+

Q3

Which of these areas is the closest to you?

Location 1

Location 2

Location 3

Q4

Please check all that apply

Anemia

Asthma

Arthritis

Cancer

Gout

Diabetes

Epilepsy Seizures

Heart Disease

Heart Attack

Rheumatic Fever

High Blood Pressure

Digestive Problems

Ulcerative Colitis

Hepatitis

Kidney Disease

Liver Disease

Thyroid Problems

Tuberculosis

Venereal Disease

Neurological Disorders

Bleeding Dİsorders

Lung Disease (Chronic Obstructive Pulmonary Disease)

Q5

Name

First Name

Q6

Name

Last Name

Q7

Email

Q8

Address

Street Address

Q9

Address

Street Address Line 2

Q10

Address

City

Q11

Address

State / Province

Q12

Address

Postal / Zip Code

Q13

Phone Number

Q14

Testing Appointment -Form Fill

Are you currently experiencing any symptoms?

Please select your age group

Which of these areas is the closest to you?

Please check all that apply

Name

Name

Email

Address

Address

Address

Address

Address

Phone Number

Signature