Skip survey header

COVID-19 Health Assessment

ITA COVID-19 Health Assessment

This question requires a valid date format of MM/DD/YYYY.
calendar
3. Are you experiencing any of the following symptoms:

 
  • difficulty breathing (e.g. unable to finish sentences because of your breathing, short of breath at rest, unable to lie down because of difficulty breathing); 
  • chest pain;
  • having a very hard time waking up; 
  • fainted or lost consciousness; OR
  • difficulty managing your daily life because of breathing difficulties.
*This question is required.
4. Are you experiencing any of the following symptoms:

 
  • Fever
  • New or worsening cough
  • Shortness of breath
  • Tiredness
  • Generally feeling unwell
  • Sore throat
  • Muscle aches
     
  • Runny nose
  • Headache
  • Diarrhea
  • Vomiting
  • Loss of sense of smell
*This question is required.
0%