Questions about a patient's recent COVID-19 history
Public Health History
question 1: Places visited in last 14 days
question 2: Previous positive COVID-19 test? *
question 2-1: Month of positive COVID-19 test? * Answer options for p01-q02-1-PrevPositiveMonth January February March April May June July August September October November December ??
Answer options for p01-q02-1-PrevPositiveMonth
question 2-2: Year of positive COVID-19 test? * Answer options for p01-q02-2-PrevPositiveYear 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 ??
Answer options for p01-q02-2-PrevPositiveYear
question 3: High suspicion of prev. COVID-19? *
question 4: Potential close contact with a COVID-19 positive person in the last 14 days? *
question 5: COVID-19 vaccine? * Answer options for p01-q05-COVID19Vaccine null#null ("Full") null#null ("Partial") null#null ("Nil") ??
Answer options for p01-q05-COVID19Vaccine
question 6 - 1st Dose: Date
question 6 - 1st Dose: Vaccine given Answer options for p01-q06-dose1-vaccine null#207 ("Moderna") null#208 ("Pfizer/BioNtech") null#210 ("AstraZeneca / Covishield") null#211 ("Novavax") null#212 ("Janssen") null#505 ("Sputnik V") null#510 ("Sinopharm") null#511 ("CoronaVac") ??
Answer options for p01-q06-dose1-vaccine
question 6 - 1st Dose: Country where vaccinated Ascension Island Andorra United Arab Emirates (the) Afghanistan Antigua and Barbuda Anguilla Albania Armenia Netherlands Antilles Angola African Regional Industrial Property Organization Antarctica Argentina American Samoa Austria Australia Aruba Åland Islands Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Saint Barthélemy Bermuda Brunei Darussalam Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Brazil Bahamas (the) Bhutan Burma Bouvet Island Botswana Benelux Trademarks and Designs Office Belarus Belize Canada Cocos (Keeling) Islands (the) Congo (the Democratic Republic of the) Central African Republic (the) Congo (the) Switzerland Côte d'Ivoire Cook Islands (the) Chile Cameroon China Colombia Clipperton Island Costa Rica Czechoslovakia Canton and Enderbury Islands Cuba Cabo Verde Curaçao Christmas Island Cyprus Czechia German Democratic Republic Germany Diego Garcia Djibouti Denmark Dominica Dominican Republic (the) Dahomey Algeria Ceuta, Melilla Ecuador Estonia Union of Countries under the European Community Patent Convention Egypt Western Sahara* European Trademark Office European Patent Organization Eritrea Spain Ethiopia European Union Eurasian Patent Organization Estonia Finland Fiji Falkland Islands (the) [Malvinas] Liechtenstein Micronesia (Federated States of) Faroe Islands (the) French Southern and Antarctic Territories France France, Metropolitan Gabon United Kingdom of Great Britain and Northern Ireland (the) Patent Office of the Cooperation Council for the Arab States of the Gulf (GCC) Grenada Georgia French Guiana Guernsey Ghana Gibraltar Greenland Gambia (the) Guinea Guadeloupe Equatorial Guinea Greece South Georgia and the South Sandwich Islands Guatemala Guam Guinea-Bissau Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Upper Volta International Bureau of WIPO Canary Islands Indonesia Ireland Israel Isle of Man India British Indian Ocean Territory (the) Iraq Iran (Islamic Republic of) Iceland Italy Jamaica Jersey Jamaica Jordan Japan Johnston Island Kenya Kyrgyzstan Cambodia Kiribati Comoros (the) Saint Kitts and Nevis Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Cayman Islands (the) Kazakhstan Lao People's Democratic Republic (the) Lebanon Saint Lucia Libya Fezzan Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libya Morocco Monaco Moldova (the Republic of) Montenegro Saint Martin (French part) Madagascar Marshall Islands (the) Midway Islands Macedonia (the former Yugoslav Republic of) Mali Myanmar Mongolia Macao Northern Mariana Islands (the) Martinique Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia Niger (the) Norfolk Island Nigeria New Hebrides Nicaragua Netherlands (the) Norway Nepal Dronning Maud Land Nauru Neutral Zone Niue New Zealand African Intellectual Property Organization Oman Panama Pacific Islands (Trust Territory) Peru French Polynesia Papua New Guinea Philippines (the) Philippines Pakistan Poland Saint Pierre and Miquelon Pitcairn Puerto Rico Palestine, State of Portugal United States Miscellaneous Pacific Islands Palau Paraguay Panama Canal Zone Qatar Argentina Bolivia [cf. Botswana: identical code element] China Réunion Southern Rhodesia Indonesia Lebanon Madagascar Niger Romania Philippines Serbia Russian Federation (the) Rwanda Saudi Arabia Solomon Islands Seychelles Sudan (the) Sweden Finland Singapore Saint Helena, Ascension and Tristan da Cunha Slovenia Svalbard and Jan Mayen Slovakia Sierra Leone San Marino Senegal Somalia Suriname South Sudan Sao Tome and Principe USSR El Salvador Sint Maarten (Dutch part) Syrian Arab Republic Eswatini Tristan da Cunha Turks and Caicos Islands (the) Chad French Southern Territories (the) Togo Thailand Tajikistan Tokelau Timor-Leste Turkmenistan Tunisia Tonga East Timor Turkey Trinidad and Tobago Tuvalu Taiwan (Province of China) Tanzania, United Republic of Ukraine Uganda United Kingdom United States Minor Outlying Islands (the) United States of America (the) Uruguay Uzbekistan Holy See (the) Saint Vincent and the Grenadines Viet-Nam, Democratic Republic of Venezuela (Bolivarian Republic of) Virgin Islands (British) Virgin Islands (U.S.) Viet Nam Vanuatu Wallis and Futuna Grenada Wake Island Saint Lucia World Intellectual Property Organization Samoa Saint Vincent Yemen, Democratic Yemen Mayotte Yugoslavia Venezuela South Africa Zambia Zaire Zimbabwe
question 6 - 2nd Dose: Date
question 6 - 2nd Dose: Vaccine given Answer options for p01-q06-dose2-vaccine null#207 ("Moderna") null#208 ("Pfizer/BioNtech") null#210 ("AstraZeneca / Covishield") null#211 ("Novavax") null#212 ("Janssen") null#505 ("Sputnik V") null#510 ("Sinopharm") null#511 ("CoronaVac") ??
Answer options for p01-q06-dose2-vaccine
question 6 - 2nd Dose: Country where vaccinated Ascension Island Andorra United Arab Emirates (the) Afghanistan Antigua and Barbuda Anguilla Albania Armenia Netherlands Antilles Angola African Regional Industrial Property Organization Antarctica Argentina American Samoa Austria Australia Aruba Åland Islands Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Saint Barthélemy Bermuda Brunei Darussalam Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Brazil Bahamas (the) Bhutan Burma Bouvet Island Botswana Benelux Trademarks and Designs Office Belarus Belize Canada Cocos (Keeling) Islands (the) Congo (the Democratic Republic of the) Central African Republic (the) Congo (the) Switzerland Côte d'Ivoire Cook Islands (the) Chile Cameroon China Colombia Clipperton Island Costa Rica Czechoslovakia Canton and Enderbury Islands Cuba Cabo Verde Curaçao Christmas Island Cyprus Czechia German Democratic Republic Germany Diego Garcia Djibouti Denmark Dominica Dominican Republic (the) Dahomey Algeria Ceuta, Melilla Ecuador Estonia Union of Countries under the European Community Patent Convention Egypt Western Sahara* European Trademark Office European Patent Organization Eritrea Spain Ethiopia European Union Eurasian Patent Organization Estonia Finland Fiji Falkland Islands (the) [Malvinas] Liechtenstein Micronesia (Federated States of) Faroe Islands (the) French Southern and Antarctic Territories France France, Metropolitan Gabon United Kingdom of Great Britain and Northern Ireland (the) Patent Office of the Cooperation Council for the Arab States of the Gulf (GCC) Grenada Georgia French Guiana Guernsey Ghana Gibraltar Greenland Gambia (the) Guinea Guadeloupe Equatorial Guinea Greece South Georgia and the South Sandwich Islands Guatemala Guam Guinea-Bissau Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Upper Volta International Bureau of WIPO Canary Islands Indonesia Ireland Israel Isle of Man India British Indian Ocean Territory (the) Iraq Iran (Islamic Republic of) Iceland Italy Jamaica Jersey Jamaica Jordan Japan Johnston Island Kenya Kyrgyzstan Cambodia Kiribati Comoros (the) Saint Kitts and Nevis Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Cayman Islands (the) Kazakhstan Lao People's Democratic Republic (the) Lebanon Saint Lucia Libya Fezzan Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libya Morocco Monaco Moldova (the Republic of) Montenegro Saint Martin (French part) Madagascar Marshall Islands (the) Midway Islands Macedonia (the former Yugoslav Republic of) Mali Myanmar Mongolia Macao Northern Mariana Islands (the) Martinique Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia Niger (the) Norfolk Island Nigeria New Hebrides Nicaragua Netherlands (the) Norway Nepal Dronning Maud Land Nauru Neutral Zone Niue New Zealand African Intellectual Property Organization Oman Panama Pacific Islands (Trust Territory) Peru French Polynesia Papua New Guinea Philippines (the) Philippines Pakistan Poland Saint Pierre and Miquelon Pitcairn Puerto Rico Palestine, State of Portugal United States Miscellaneous Pacific Islands Palau Paraguay Panama Canal Zone Qatar Argentina Bolivia [cf. Botswana: identical code element] China Réunion Southern Rhodesia Indonesia Lebanon Madagascar Niger Romania Philippines Serbia Russian Federation (the) Rwanda Saudi Arabia Solomon Islands Seychelles Sudan (the) Sweden Finland Singapore Saint Helena, Ascension and Tristan da Cunha Slovenia Svalbard and Jan Mayen Slovakia Sierra Leone San Marino Senegal Somalia Suriname South Sudan Sao Tome and Principe USSR El Salvador Sint Maarten (Dutch part) Syrian Arab Republic Eswatini Tristan da Cunha Turks and Caicos Islands (the) Chad French Southern Territories (the) Togo Thailand Tajikistan Tokelau Timor-Leste Turkmenistan Tunisia Tonga East Timor Turkey Trinidad and Tobago Tuvalu Taiwan (Province of China) Tanzania, United Republic of Ukraine Uganda United Kingdom United States Minor Outlying Islands (the) United States of America (the) Uruguay Uzbekistan Holy See (the) Saint Vincent and the Grenadines Viet-Nam, Democratic Republic of Venezuela (Bolivarian Republic of) Virgin Islands (British) Virgin Islands (U.S.) Viet Nam Vanuatu Wallis and Futuna Grenada Wake Island Saint Lucia World Intellectual Property Organization Samoa Saint Vincent Yemen, Democratic Yemen Mayotte Yugoslavia Venezuela South Africa Zambia Zaire Zimbabwe
question 6 - 3rd Dose: Date
question 6 - 3rd Dose: Vaccine given Answer options for p01-q06-dose3-vaccine null#207 ("Moderna") null#208 ("Pfizer/BioNtech") null#210 ("AstraZeneca / Covishield") null#211 ("Novavax") null#212 ("Janssen") null#505 ("Sputnik V") null#510 ("Sinopharm") null#511 ("CoronaVac") ??
Answer options for p01-q06-dose3-vaccine
question 6 - 3rd Dose: Country where vaccinated Ascension Island Andorra United Arab Emirates (the) Afghanistan Antigua and Barbuda Anguilla Albania Armenia Netherlands Antilles Angola African Regional Industrial Property Organization Antarctica Argentina American Samoa Austria Australia Aruba Åland Islands Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Saint Barthélemy Bermuda Brunei Darussalam Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Brazil Bahamas (the) Bhutan Burma Bouvet Island Botswana Benelux Trademarks and Designs Office Belarus Belize Canada Cocos (Keeling) Islands (the) Congo (the Democratic Republic of the) Central African Republic (the) Congo (the) Switzerland Côte d'Ivoire Cook Islands (the) Chile Cameroon China Colombia Clipperton Island Costa Rica Czechoslovakia Canton and Enderbury Islands Cuba Cabo Verde Curaçao Christmas Island Cyprus Czechia German Democratic Republic Germany Diego Garcia Djibouti Denmark Dominica Dominican Republic (the) Dahomey Algeria Ceuta, Melilla Ecuador Estonia Union of Countries under the European Community Patent Convention Egypt Western Sahara* European Trademark Office European Patent Organization Eritrea Spain Ethiopia European Union Eurasian Patent Organization Estonia Finland Fiji Falkland Islands (the) [Malvinas] Liechtenstein Micronesia (Federated States of) Faroe Islands (the) French Southern and Antarctic Territories France France, Metropolitan Gabon United Kingdom of Great Britain and Northern Ireland (the) Patent Office of the Cooperation Council for the Arab States of the Gulf (GCC) Grenada Georgia French Guiana Guernsey Ghana Gibraltar Greenland Gambia (the) Guinea Guadeloupe Equatorial Guinea Greece South Georgia and the South Sandwich Islands Guatemala Guam Guinea-Bissau Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Upper Volta International Bureau of WIPO Canary Islands Indonesia Ireland Israel Isle of Man India British Indian Ocean Territory (the) Iraq Iran (Islamic Republic of) Iceland Italy Jamaica Jersey Jamaica Jordan Japan Johnston Island Kenya Kyrgyzstan Cambodia Kiribati Comoros (the) Saint Kitts and Nevis Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Cayman Islands (the) Kazakhstan Lao People's Democratic Republic (the) Lebanon Saint Lucia Libya Fezzan Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libya Morocco Monaco Moldova (the Republic of) Montenegro Saint Martin (French part) Madagascar Marshall Islands (the) Midway Islands Macedonia (the former Yugoslav Republic of) Mali Myanmar Mongolia Macao Northern Mariana Islands (the) Martinique Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia Niger (the) Norfolk Island Nigeria New Hebrides Nicaragua Netherlands (the) Norway Nepal Dronning Maud Land Nauru Neutral Zone Niue New Zealand African Intellectual Property Organization Oman Panama Pacific Islands (Trust Territory) Peru French Polynesia Papua New Guinea Philippines (the) Philippines Pakistan Poland Saint Pierre and Miquelon Pitcairn Puerto Rico Palestine, State of Portugal United States Miscellaneous Pacific Islands Palau Paraguay Panama Canal Zone Qatar Argentina Bolivia [cf. Botswana: identical code element] China Réunion Southern Rhodesia Indonesia Lebanon Madagascar Niger Romania Philippines Serbia Russian Federation (the) Rwanda Saudi Arabia Solomon Islands Seychelles Sudan (the) Sweden Finland Singapore Saint Helena, Ascension and Tristan da Cunha Slovenia Svalbard and Jan Mayen Slovakia Sierra Leone San Marino Senegal Somalia Suriname South Sudan Sao Tome and Principe USSR El Salvador Sint Maarten (Dutch part) Syrian Arab Republic Eswatini Tristan da Cunha Turks and Caicos Islands (the) Chad French Southern Territories (the) Togo Thailand Tajikistan Tokelau Timor-Leste Turkmenistan Tunisia Tonga East Timor Turkey Trinidad and Tobago Tuvalu Taiwan (Province of China) Tanzania, United Republic of Ukraine Uganda United Kingdom United States Minor Outlying Islands (the) United States of America (the) Uruguay Uzbekistan Holy See (the) Saint Vincent and the Grenadines Viet-Nam, Democratic Republic of Venezuela (Bolivarian Republic of) Virgin Islands (British) Virgin Islands (U.S.) Viet Nam Vanuatu Wallis and Futuna Grenada Wake Island Saint Lucia World Intellectual Property Organization Samoa Saint Vincent Yemen, Democratic Yemen Mayotte Yugoslavia Venezuela South Africa Zambia Zaire Zimbabwe
Produced 08 Sep 2023