Magnifica | Corona Virus Covid-19 Questionnaire Form Wizard by Ansonika

Have you traveled to any one of the destinations below in the last 21 days?

China

South Korea

Iran

Europe

US States

None of the above

Have you recently been in contact with a person with Coronavirus?

Yes No

Are you experiencing any difficulty in breathing?

Yes No

* Start branch radio based

Please tick any one of the following symptoms that can be applies to you.

Shortness of breath or breathing very fast

Shortness of breath & Intense chest pain.

Cannot complete a long sentence in one breath.

None of the above

Do you have fever higher than 100.3° F?

Yes No

Are you experiencing muscle aches, weakness, or lightheadedness?

Yes No

Are you having diarrhea, stomach pain, vomiting?

Yes No

Please fill with your personal data

First and Last Name

Email Address

Phone

Age

Male Female

Thank your for your time
!

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CORONAVIRUS Questionnaire with Branch

Have you traveled to any one of the destinations below in the last 21 days?

Have you recently been in contact with a person with Coronavirus?

Are you experiencing any difficulty in breathing?

Please tick any one of the following symptoms that can be applies to you.

Do you have fever higher than 100.3° F?

Do you have a runny nose?

Are you experiencing muscle aches, weakness, or lightheadedness?

Are you having diarrhea, stomach pain, vomiting?

Please fill with your personal data

Thank your for your time
!

CORONAVIRUS Questionnaire with Branch

Have you traveled to any one of the destinations below in the last 21 days?

Have you recently been in contact with a person with Coronavirus?

Are you experiencing any difficulty in breathing?

Please tick any one of the following symptoms that can be applies to you.

Do you have fever higher than 100.3° F?

Do you have a runny nose?

Are you experiencing muscle aches, weakness, or lightheadedness?

Are you having diarrhea, stomach pain, vomiting?

Please fill with your personal data

Thank your for your time!

Thank your for your time
!