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Medical Assessment Form -Form Fill
Q1
Full Name*
Q2
Gender*
Please Select
Male
Female
Not willing to Disclose
Q3
Day
Date of Birth*
1
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Q4
Month
Date of Birth*
January
February
March
April
May
June
July
August
September
October
November
December
Q5
Year
Date of Birth*
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1927
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1925
1924
1923
1922
1921
1920
Q6
Street Address
Address*
Q7
City
Address*
Q8
Have you been vaccinated for Covid-19?*
Yes
No
Q9
What vaccine?
Pfizer- BioNTech
Oxford- AztraZeneca
CoronaVac- SinoVac
Johnson and Johnson's- Janssen'
Gamelaya- Sputnik
Moderna
Q10
Have you had any direct contact with a confirmed case of Covid-19?
Yes
No
If Yes, how many times have you been exposed to Covid-19 Positive cases?
Q11
Where did you get your exposure to Covid-19 from?
Family Member
Relative
Workmates
Friends
Q12
Have you been tested positive for Covid-19?
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