Survey COVID-19 Last Name First Name Age Phone Number Do you suffer from heart, lung, kidney or liver problems ? YesNo Do you have unbalanced diabetes ? YesNo Do you have a medical condition or treatment that lowers your immunity ? YesNo Do you have any other health problems ? YesNo Your height in cm Your weight in kg Are you pregnant in your third trimester ? YesNoNot applicable To date and in the last 3 weeks have you had any of the following symptoms : Fever (>38°C)Breathing difficultySudden loss of tasteSudden loss of sense of smellSore throatDiarrhoeaDry coughBody achesHeadachesNausea, vomitingNone In the last 14 days, have you been in close contact with : - a person with these symptoms ? YesNo - a person diagnosed with COVID-19 ? YesNo Have you been tested positive for COVID-19 ? YesNo I certify on my honour the accuracy of the information on this day. {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…