33. Were you treated in intensive care unit? | ☐ Yes | ☐ No | ☐ Unknown | ||
34. Did you receive oxygen therapy | ☐ Yes | ☐ No | ☐ Unknown | ||
35. Did you receive mechanical ventilation of lungs | ☐ Yes | ☐ No | ☐ Unknown | ||
Pre-existing medical conditions? | |||||
36. Chronic Lung Disease (asthma/emphysema/COPD | ☐ Yes | ☐ No | ☐ Unknown | ||
37. Diabetes Mellitus | ☐ Yes | ☐ No | ☐ Unknown | ||
38. Cardiovascular diseas | ☐ Yes | ☐ No | ☐ Unknown | ||
39. Chronic Renal disease | ☐ Yes | ☐ No | ☐ Unknown | ||
40. Chronic Liver disease | ☐ Yes | ☐ No | ☐ Unknown | ||
41. Immunocompromised Condition | ☐ Yes | ☐ No | ☐ Unknown | ||
42. Other chronic diseases (please mention) | |||||
43. If female, currently pregnant | ☐ Yes | ☐ No | ☐ Unknown | ||
44. If yes, please mention gestation weeks | |||||
45. Do you smoke? | ☐ Yes | ☐ No | ☐ Unknown | ||
46. If yes, please mention how many cigarettes a day? __________ | |||||
47. (if 45 is “no”) Are you a former smoker? | ☐ Yes | ☐ No | ☐ Unknown | ||
48. Did you have acute respiratory infection during last one year? | ☐ Yes | ☐ No | ☐ Unknown | ||
49. Did you take antibiotics during last one year? | ☐ Yes | ☐ No | ☐ Unknown | ||
50. Did you take antiviral drugs during last one year? | ☐ Yes | ☐ No | ☐ Unknown | ||
51. Did you receive influenza vaccine during last one year? | ☐ Yes | ☐ No | ☐ Unknown | ||
52. Did you receive all the vaccines indicated in national immunization plan (MMR, OPV, BCG, DPT and etc.) | ☐ Yes | ☐ No | ☐ Unknown | ||
53. Can we also contact you months later and invite you for additional testing to identify the titer of antibodies in your blood? | ☐ Yes | ☐ No | ☐ Unknown | ||
THANK YOU FOR TAKING YOUR TIME AND ANSWERING THIS QUESTIONNAIRE | |||||
Name of person filling the questionnaire________________________________Signature________________ | |||||