Lostisland COVID-19 Questionnarie
Dear citizens,

As the COVID-19 pandemic continues ravaging the world, we're trying to keep track of how many Lostislandians contracted the disease and if we could be of any help.

Lostisland as an organization isn't authorized to demand medical information, filling this in is 100% voluntary. But if you're a Lostislandic citizen who tested positive for COVID-19 and would like to get support or share your experience with other citizens, we invite you to fill in this form.
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Email *
Citizen Name *
Date Developed Sympthoms *
MM
/
DD
/
YYYY
Date COVID-19 Confirmed *
MM
/
DD
/
YYYY
Date Hospitalized (if applicable) *
MM
/
DD
/
YYYY
Date Discharged from Hospital (if applicable) *
MM
/
DD
/
YYYY
Date Tested Negative (if applicable) *
MM
/
DD
/
YYYY
What is your current condition? *
Would you be willing to share your story with other Lostislandic citizens? *
Anything else you'd like to add?
Submit
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