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Questionnaire for COVID-19 Antibody Testing
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* Indicates required question
Email
*
Your email
First Name
*
Please enter name as it appears on your legal photo ID.
Your answer
Last Name
*
Please enter name as it appears on your legal photo ID.
Your answer
DOB
*
MM
/
DD
/
YYYY
Cell Phone Number
*
Your answer
Have you had symptoms of COVID-19 infection?
*
None
Fever
Cough
Shortness of Breath
Headache
Fatigue
Weakness
Muscle or Joint Aches
Nausea or Vomiting
Diarrhea
Confusion
Loss of taste or smell
Other:
Required
What date did your symptoms begin?
MM
/
DD
/
YYYY
When did your symptoms substantially end?
MM
/
DD
/
YYYY
Were you treated for COVID-19?
Yes
No
N/A
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