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    Medical Assessment Form
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    Country/Region
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    Have you been vaccinated for Covid-19?
    YesNo
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    What vaccine?
    Select OptionPfizer - BioNTechOxford - AztraZenecaCoronaVac - SinoVacJohnsons and Johnson's - JanssenGamelaya - SputnikModerna
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    When did you get your 1st shot?
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    Your 2nd shot?
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    Have you had any direct contact with a confirmed case of Covid-19?
    YesNoIf Yes, how many times have you been exposed to Covid-19 Positive cases?
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    Where did you get your exposure to Covid-19 from?
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    Have you been tested positive for Covid-19?
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    PERSONAL MEDICAL HISTORY
    ALLERGY:
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    ALLERGIC REACTION:
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    MEDICATIONS:
    Disease
    Select OptionAsthmaCancer (Type)Diabetes (Type)High Blood Pressure (Hypertension)Heart DiseaseRenal/Kidney DiseaseMigraine HeadachesHigh CholesterolOther
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    CurrentPast
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    Date Diagnosed, Experienced Symptoms, Treatment
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    Other Minor Health Complaints (e.g Headache, Back Pain)
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    SURGERIES:
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    Date of Surgery
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    Location/Facility
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    MEDICATIONS:
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    Dose(how many milligram)
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    Times Per Day
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    Mental Health
    In the past 4 weeks,
    1. How often did you feel tired for no good reason?
    None of the timeA little of the timeSome of the timeMost of the timeAll of the time
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    2. How often did you feel nervous?
    None of the timeA little of the timeSome of the timeMost of the timeAll of the time
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    3. How often did you feel so nervous that nothing can calm you down?
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    4. How often did you feel hopeless?
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    5. How often did you feel restless?
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    6. How often did you feel so restless that you could not sit still?
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    7. How often did you feel depressed?
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    8. How often did you feel that everything was an effort
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    9. How often did you feel so sad that nothing could cheer you up?
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    10. How often did you feel that you're worthless?
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