Covid-19 Survey Questionnaire Form
Please indicate your age
Gender
Male
Female
Marital status
Married
Widowed
Separated
Diivorced
Single
Do you have children?
Yes
No
Do you have parents living with you at home?
Yes
No
How would you describe yourself?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
What is the highest level of education?
Middle School
High School
1-3 years of college
Graduated from College
Completed Graduate School
Co-morbidities and Current Medication:
Select all that apply to you
Gastro-esophageal reflux disease
Inflammatory bowel disease
Eosinophilic Esophagitis
Irritable bowel syndrome
Celiac disease
Chronic liver disease
Chronic heart disease
Chronic kidney disease
Chronic lung disease
Diabetes
Hypertension
High cholesterol
None of these
Other
Please specify
Choose all that apply for the groups of medications you are on:
Acid suppressive medications
Antacids
Steroids
Biologic agents
Disease modifying agents
BP lowering medications
Oral diabetic medications
Cholesterol lowering medications
None of these
Other
Please specify
Have you had any exposure to a COVID-19 infected person?
Yes
No
Don't know
Have you had any symptoms suggestive of COVID-19 infection since the beginning of this pandemic?
Yes
No
Were you tested for COVID-19 infection?
Yes
No
Did you test positive for COVID-19 infection?
Yes
No
Knowledge and source of information regarding the pandemic
Where do you get information about your behavior regarding COVID-19 infection?
Television/News Sites/Newspaper
Blogs and forums / Social Media
Friends/Family
Physician
Other
Please specify
In your opinion, what percentage of people who get the COVID-19 infection, end up dying from it?
0-5%
10-20%
50-60%
90-100%
What percentage of people who get the influenza (Flu) do you think die from it?
< 1%
5-10%
50-60%
80-90%
Do you think a vaccine will be able to prevent COVID-19 infection?
Yes
No
No idea
Are you concerned about getting infected with COVID-19?
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
Are you concerned that you would die if you get the COVID-19 infection?
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
Are you concerned that you would get COVID-19 infection in public places?
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
How concerned are you regarding getting infected with COVID-19 if you were to visit the hospital?
Not concerned
1
2
3
4
Very concerned
5
1 is Not concerned, 5 is Very concerned
Attitudes and concern related to COVID-19 and healthcare
Are you concerned that the COVID-19 pandemic will have an impact on the treatment or follow-up of your medical condition?
Yes
No
No idea
Submit
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