Covid Study Submission Form
Michigan Center of Medical Research
Please fill out the information below
Date of Birth
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Were you diagnosed with Covid-19 (Your symptoms must have started within the past 7 days)?
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Check the symptoms you have now
Are you able to take oral medication?
*
MEDICAL CONDITIONS
Have you been diagnosed with cancer?
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Have you been diagnosed with kidney disease?
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Have you been diagnosed with obstructive pulmonary disease?
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Have you been diagnosed with chronic obstructive pulmonary disease?
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Have you been diagnosed with diabetes mellitus?
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Have you been diagnosed with serious heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
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Have you taken the COVID-19 vaccine?
THIS PAGE FOR FEMALE CANDIDATES ONLY
If you are male, please skip this page
Are you pregnant or breastfeeding?
Are you of childbearing potential?