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________________