COVID19 Survey Form

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Mail-ID
Name

Age
Gender
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Region
Check the symptoms that you have experienced in the PAST 6 WEEKS
Fever/Chills Headaches/Migraines Dizziness Shortness of breath Chest pain, pressure or tightness Feelings of Guilt Feelings of Guilt Thoughts of harming self or others
Are you currently taking any medication?
Yes No
If so, please list:

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