Viral Infection Assessment Survey
Please complete this survey to help assess symptoms and risk factors related to viral infections.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Please select any symptoms you are currently experiencing:
*
Fever
Cough
Sore throat
Fatigue
Shortness of breath
Headache
Loss of taste or smell
Other
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been in close contact with anyone diagnosed with a viral infection in the past 14 days?
*
Yes
No
Not sure
Have you traveled internationally or to an area with known outbreaks in the last month?
*
Yes
No
Do you have any pre-existing health conditions? (e.g., asthma, diabetes, immunosuppression)
Submit Assessment
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