Have you been vaccinated for COVID-19?
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Yes
No
When did you first notice your symptoms?
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MM slash DD slash YYYY
Date of positive COVID-19 test?
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MM slash DD slash YYYY
Testing site of positive COVID-19 test?
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Are you a current FHCSD patient or employee?
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Yes
No
Are you a health care provider?
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Yes
No
Who is your current health care provider? (if applicable)
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Do you have any of the following health conditions? (select all that apply)
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Cancer
Overweight (BMI >25)
Cardiac disease
Obesity (BMI >35)
Chronic kidney disease
Pregnancy
Chronic lung disease
Smoking, current or former
Diabetes
Other
Hypertension
None
Immunocompromised state (weakened immune system)
Other
Other
Name
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First
Last
Email
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Phone
County of Residence
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San Diego County
Other
Date of Birth
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MM slash DD slash YYYY
Other
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