Corona questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We ask you kindly to fill out this form before you sit down.

In the past 24 hours, have you experienced one or more of the following symptoms? *

1 point

excessive sneezing

coughing

>38 degrees fever

stuffiness

I have none of these symptoms

Required

Do you share a home with somebody that right now is experiencing fever or cold sypmtoms? *

1 point

Yes

In the past 14 days, were you tested and diagnosed positive for the corona virus? *

1 point

Yes

Do you share a home with somebody that In the past 14 days, was tested and diagnosed positive for the corona virus? *

1 point

Yes

First and last name *

E-mail *

Phone number *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy