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COVID-19 Survey Template + Sample Questionnaire

Use this COVID-19 survey template to gather data related to the health and medical history of people. Find out if the person is likely to be already infected. Learn more about the health problems of the patients whether young or senior citizens.

This sample Coronavirus questionnaire asks questions based on commonly found symptoms in a majority of patients. Customize this COVID-19 research template as per your needs. Use this survey template to predict the next hotspot and stop the spread of the infection.


What is your date of birth?
Please enter your details.
What is your gender?
Do you experience any of the below symptoms?
No
Slight
Medium
Heavy
Cold
Fever
Cough
Shortness of breath
Headache
Muscle pain
Sore throat
Diarrhea
Olfactory disorders
Taste disorders
No
Slight
Medium
Heavy
Exhaustion
Do you experience any other difficulties?
Do you suffer from any of the below diseases?
Do you have a travel history to any of these countries?
Approximately, how many people have you come in contact with in past 15 days?
Have you already shared your medical history with government authorities?
How many senior citizens do you have at home?
Have you been tested at airport or hospital?
Are you pregnant? If yes, select the number of weeks.
Do you smoke?
Do you drink alcohol?
Do you work in any of these high risk occupations?

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