General Health Questionnaire

How would you rate your general health?

• Excellent

• Good

• Fair

• Poor

Describe your usual level of social interactions with other people when not under stay at home and/or social distancing.

• I go out a lot (4-7 times/week)

• I go out sometimes (2-3 times/week)

• I keep to myself mainly (1 or less times/week)

How would you rate your compliance on a scale of 1-5 about social distancing measures as recommended by CDC? (1 being not following guidelines to 5 being following all guidelines).

• 1

• 2

• 3

• 4

• 5

Has your doctor or any medical provider ever told you that you have any of the following diseases? (check all that apply)

• Lung disease

• Anemia

• Hyperlipidemia/ hypercholesterolemia/high cholesterol

• Heart disease

• Hypertension/high blood pressure

Have you ever had an organ transplant?

• No

• yes, which organ?

Have you ever been diagnosed with an immune related condition?

• Immune deficiency

• Periodic/Frequent fevers

• Inflammatory condition - which one:

• Autoimmune condition (indicate all the apply)

• Recurrent warts or viral skin infections

Are you currently taking any of the following daily, several times a week or at least once a week? (Check all that apply)

• Acetaminophen (Tylenol and others)

• Aspirin, with or without a prescription.

• Inhaled corticosteroids (eg. fluticasone (Flovent), beclomethasone (QVar), etc)

• Non-steroidal anti-inflammatory agents (NSAIDS) with or without a prescription

• Oral corticosteroids (eg. Prednisone)

Did you get a flu vaccine this season (last 6 months)?

• Yes, date (if remember)

• No

• Do not remember

Do you remember last time you got flu or flu-like illness prior to COVID pandemic?

• Yes, When?

• No

How often do you get flu or flu-like illness?

• Never

• Rarely

• Once a year

• Twice a year or more