Your name

Your email

1. Demographics

Q1. Which is your biological sex?
MaleFemaleOtherPrefer not to say

Q2. Your Date of Birth

Q3. Do you have any of these medical conditions? (can choose more than one) (*)
NonePrefer not to sayAsthmaCystic fibrosisCOPD/EmphysemaPulmonary fibrosisOther lung diseaseHigh Blood PressureAnginaPrevious stroke or Transient ischaemic attackPrevious heart attackValvular heart diseaseOther heart diseaseDiabetesCancerPrevious organ transplantHIV or impaired immune systemOther long-term condition

Q4. Do you, or have you, ever smoked (including e-cigarettes)?
Never smokedPrefer not to sayEx-smokerCurrent smoker (less than once a day)Current smoker (1-10 cigarettes per day)Current smoker (11-20 cigarettes per day)Current smoker (21+ cigarettes per day)Current smoker (e-cigarettes only)

2. Symptoms

Q1. Do you have any of the following symptoms today? (can choose more than one) (*)
NonePrefer not to sayFever (feeling feverish or warmer than usual)ChillsDry coughWet coughDifficulty breathing or feeling short of breathTightness in your chestLoss of taste and smellDizziness, confusion or vertigoHeadacheMuscle achesSore throat, runny or blocked nose

Q2. Have you had a positive test for COVID-19?
NeverIn the last 14 daysMore than 14 days agoPrefer not to say

Q3. Are you in the hospital right now?
NoYesPrefer not to say

I hope my data can help to manage the virus pandemic. [breathe]
I hope my data can help to manage the virus pandemic. [breathe]
I hope my data can help to manage the virus pandemic. [breathe]

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