Covid Study Submission Form

Michigan Center of Medical Research

Please fill out the information below

Full Name

*

Gender

*

Male

Female

Date of Birth

*

Year

Month

Day

Weight (lbs)

*

Height (inches)

*

Email

*

Phone Number

*

Address

*

Were you diagnosed with Covid-19 (Your symptoms must have started within the past 7 days)?

*

Yes

No

Check the symptoms you have now

Cough

Sore throat

Nasal congestion

Runny nose

Shortness of breath or difficulty breathing with exertion

Muscle or body aches

Fatigue

Fever >38.0◦C

Chills

Headache

Nausea

Vomiting

Diarrhea

Loss of smell

Loss of taste

Are you able to take oral medication?

*

Yes

No

MEDICAL CONDITIONS

Have you been diagnosed with cancer?

*

Yes

No

Have you been diagnosed with kidney disease?

*

Yes

No

Have you been diagnosed with obstructive pulmonary disease?

*

Yes

No

Have you been diagnosed with chronic obstructive pulmonary disease?

*

Yes

No

Have you been diagnosed with diabetes mellitus?

*

Yes

No

Have you been diagnosed with serious heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)

*

Yes

No

Have you taken the COVID-19 vaccine?

Yes

No

THIS PAGE FOR FEMALE CANDIDATES ONLY

If you are male, please skip this page

Are you pregnant or breastfeeding?

Yes

No

Are you of childbearing potential?

Yes

No