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Are you a confirmed COVID-19 patient?

Yes

No

Have you been tested?

Yes

No

When were you diagnosed?

How old are you?

Enter your country

Enter Height in feet and inches

Enter Weight in Ibs

Enter Gender

Underlying Conditions

Have you used a ventilator?

Yes

No

Enter Race

Submit

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Were you hospitalized?

Yes

No

For how many days were you hospitalized?

Please enter your contact information

Not a valid Email address

Treatment Medicine

Check Symptoms that Apply

Fever

Trouble Breathing

Loss of Taste

Dry Cough

Loss of smell

None

Other

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