Do you have any Covid symptoms Yes No GDPR Consent I give my consent for my personal data and medical files to be used in this questionnaire. First name* Last Name* Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mark the location of your worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord1HiddenYcoord1 HiddenIMGX1HiddenIMGY1Mark the location of your second worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord2HiddenYcoord2 HiddenIMGX2 HiddenIMGY2 Mark the location of your third worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord3HiddenYcoord3 HiddenIMGX3 HiddenIMGY3 HiddenAdministrative Email Δ
