In use at:

Health History

These questions about your health history ask about medical conditions and any recent use of healthcare services. Answer every question by selecting the most appropriate response. If you are unsure about how to answer a question, please give the best answer you can.

Have you ever been told by a doctor or health professional that you have:

Diabetes (other than when you were pregnant)

Chronic obstructive pulmonary disease (COPD) or emphysema, or Chronic Bronchitis

Asthma

Cystic fibrosis

Hypertension (also called high blood pressure)

Had a heart attack (also called myocardial infarction)

Had a stroke

Coronary Atherosclerosis or Other Heart Disease

Congestive heart failure

Rheumatic heart disease

Chronic kidney disease

Liver disease

Cancer

Neurocognitive conditions

Sickle cell anemia

HIV infection

None of the above

Contact us: covid19-info@closedloop.ai