Covid-19 Profile

Questionaire

Contra2020, for your health!
Please complete your Contra2020 Risk Profile:

Create your SYMPTOMS/TREATMENT HISTORY, complete form and select CREATE HISTORY:

1. Is your family practicing safety measures at home?

Yes No

2. Is your family interacting with friends and relatives?

Yes No

3. Do you live with more than one other person?

Yes No

4. Do you live in a private home or shared facility?

Yes No

5. Do you utilize public transportation?

Yes No

6. Do you shop for food and supplies?

Yes No

7. Are you using public gyms, or other facilities?

Yes No

8. Are you utilizing restaurants or bars for dining?

Yes No

9. Do you have a private office at work?

Yes No

10. Do you utilize a common eating area at work?

Yes No

11. Does your employer enforce the use of PPE?

Yes No

12. Are visitors allowed in your place of work?

Yes No

13. Is your workplace cleaned on a daily basis?

Yes No

14. Are you traveling for business or pleasure?

Yes No

15. Are you utilizing PPE in all public spaces?

Yes No

16. Do you clean or change PPE daily?

Yes No

17. Do you wash your hands regularly?

Yes No

18. Do you practice social disting at all times?

Yes No

19. Do you allow non-family members in your car?

Yes No

20. Are you being very cautious in your daily habits?

Yes No

Tests and Shots:

Did you receive a Flu test?

Yes No

Did you receive a Flu shot?

Yes No

Did you test positive for the Flu?

Yes No Pending

Do you have the Flu antibodies?

Yes No Pending

Did you test for Kawasaki disease?

Yes No

Did you test positive for the Kawasaki disease?

Yes No Pending

Do you have Kawasaki antibodies?

Yes No Pending

Any other symptoms?

Yes No

Any further information: