COVID-19 SURVEY FORM

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. Thank you for taking your time to fill this form.

Name

Phone Number

Age

What is your gender

Any other information about you?

Have you heard of the Corona virus (COVID-19) outbreak?

Yes No Not Sure

Tick signs and symptoms of COVID-19

Fever Dry cough Tiredness Shortness of breath Red eye Stomach pain Weakness Chest pain

Which country has the highest number of cases

What can be done to eradicate this COVID-19 disease?