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Daily Covid 19 Pre Screening Questionnaire

DAILY COVID-19 PRE-SCREENING QUESTIONNAIRE

A questionnaire used by medical organizations to learn more about potential patients interested in the COVID-19 vaccine.

Page 1

Please answer the following questions to help us determine your eligibility for the COVID-19 vaccine.

Email*

What is your full name?*

What is your date of birth?*

What is your phone number?*

What is your address?*

What is your occupation?*

Description:A Daily Covid-19 Pre-Screening Questionnaire is a medical form used to gather information about individuals interested in receiving the COVID-19 vaccine. This form helps medical organizations determine if an individual is eligible for the vaccine and if there are any potential risks or concerns.

Are you interested in receiving the COVID-19 vaccine? Before you do, you may be asked to fill out a Daily Covid-19 Pre-Screening Questionnaire. This form is used by medical organizations to gather important information about potential patients, such as their medical history, current health status, and any potential risks or concerns. By filling out this form, medical professionals can determine if an individual is eligible for the vaccine and if there are any precautions that need to be taken. This form is an important step in ensuring the safety and effectiveness of the COVID-19 vaccine.

Patient Name*

Date of Birth*

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Gender*

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Date of Birth*

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Gender*

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Full Name*

Address*

Phone Number*

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Patient Name*

Date of Birth*

Address*

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Full Name*

Date of Birth*

Nationality*

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