COVID-19 Symptoms Questionnaire

Name: *

Birthdate: *

Were you experiencing any symptoms at the time of testing with PanoHealth?

Yes

Date of COVID-19 symptom onset *

Last date of COVID-19 symptoms *

Fever *

Chills *

Tiredness *

Body Aches *

Rash *

Runny Nose *

Shortness of Breath *

Cough *

Pneumonia *

New Loss of Taste *

Loss of Appetite *

Sore Throat *

Nausea/Vomiting *

Diarrhea *

Headache *

Weakness/Loss of Speech *

Blurred Vision *

Eye Infection/Inflammation *

Chest Pain *

New Onset Irregular Heartbeat *

Heart Attack *

Email Address used for PanoHealth report: