First name
* must provide value
Last name
* must provide value
Are you a designated proxy and completing this survey on behalf of the study participant?
Yes
No
Today M-D-Y MM-DD-YYYY
What is the patient's date of birth?
* must provide value
MM-DD-YYYY format.
What is the patient's age?
* must provide value
Age in years.
Please confirm the patient's date of birth is correct:
______
* must provide value
Correct
Incorrect
PLEASE GO BACK AND CORRECT THE DATE OF BIRTH
What is the sex of the patient?
Female
Male
Undifferentiated
Unknown
Female
Male
Undifferentiated
Unknown
What is the ethnicity of the patient?
Hispanic or Latino
Not Hispanic or Latino
Hispanic or Latino
Not Hispanic or Latino
Select one.
What is the race of the patient?
Check all that apply.
Please fill in any pre-existing medical conditions.
Chronic Lung Disease (asthma/emphysema/COPD)
* must provide value
Yes
No
Diabetes Mellitus
* must provide value
Yes
No
Cardiovascular disease
* must provide value
Yes
No
Chronic Kidney disease
* must provide value
Yes
No
Chronic Liver disease
* must provide value
Yes
No
Immunocompromised Condition
* must provide value
Yes
No
Neurologic/neurodevelopmental/intellectual disability
* must provide value
Yes
No
Yes
No
Please list any other chronic diseases you have been diagnosed with by a medical provider.
Currently pregnant
* must provide value
Yes
No
Current smoker
* must provide value
Yes
No
Former smoker
* must provide value
Yes
No
Please answer the following questions regarding the trial medication use.
What is the name of the study medication?
* must provide value
MedA MedB MedC MedD
Did you take the study medication today?
* must provide value
Yes
No
Did you take the study medication as prescribed (e.g. once in the evening)?
* must provide value
Yes
No
Please upload a photo of your trial medication packet.
upload photo or video
Please fill in your current symptoms.
Fever
* must provide value
Forehead Tongue Ear Estimate
How did you measure your temperature?
none
mild
high
Thermometer reading:
* must provide value
Fahrenheit
Cough
* must provide value
Yes
No
Is your cough wet ("productive") or dry?
* must provide value
Wet
Dry
Fatigue
* must provide value
Yes
No
Fatigue
* must provide value
Do you use a device that counts your daily steps (pedometer, FitBit, smartphone app, etc.)?
* must provide value
Yes
No
How many steps have you taken today?
Steps
Chills
* must provide value
Yes
No
Muscle Aches
* must provide value
Yes
No
Muscle Aches
* must provide value
Appetite
* must provide value
Shortness of Breath
* must provide value
Yes
No
Shortness of Breath
* must provide value
Do you use any devices at home to monitor your breathing, heart rate, or heart rhythm?
SpO2 %
Systolic Blood pressure reading (top number):
Systolic/Diastolic
Diastolic Blood pressure reading (bottom number):
Systolic/Diastolic
Beats per minute (bpm)
Please upload a photo of your most recent ECG or EKG:
upload picture
Nausea or vomiting
* must provide value
Yes
No
Abdominal pain
* must provide value
Yes
No
Diarrhea
* must provide value
Yes
No
Number of bowel movements per day:
Runny nose
* must provide value
Yes
No
Headache
* must provide value
Yes
No
Sore throat
* must provide value
Yes
No
Loss of sense of smell
* must provide value
Yes
No
Loss of taste
* must provide value
Yes
No
Passing out or loss of consciousness
* must provide value
Yes
No
If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:
Trouble breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
Loss of consciousness
*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.
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