Post Coronavirus (COVID-19) recovered patient survey questionnaire Template

Looking for a paper-based survey data collection solution for your organization? Take a look at this post coronavirus (covid-19) recovered patient survey questionnaire template for your upcoming research project.

Our templates come with well-designed questions that can be machine-read to recognize the checkmarks using optical mark recognition (OMR) technologies. Open text areas recognized with handwriting recognition (HWR) technologies allowing you to write handwritten text and automatically convert to a digitized format.

This is a sample template to help doctors document the recovered Covid-19 patient cases. Keep in mind that this is incomplete survey and you should customize it to fit your research requirements.

With papersurvey.io platform you can quickly create a paper survey questionnaire that allows machine-reading the responses from the paper form.

About this template

This is a sample template to help doctors document the recovered Covid-19 patient cases. Keep in mind that this is incomplete survey and you should customize it to fit your research requirements.

Why this?

With papersurvey.io platform you can quickly create a paper survey questionnaire that allows machine-reading the responses from the paper form.

Free for medical and research staff

We offer our software for free to help stop this pandemic as soon as possible. Register for a free trial and reach out to support@papersurvey.io to obtain a free licence.

Feel free to contact us also if you need assistance to set this form up or to speed up your research and data collection.

Questions in this survey: 42, Language: English

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List of questions in this template

  1. Post Coronavirus (COVID-19) recovered patient survey questionnaire
  2. 1. Headache
  3. 1. Asthma
  4. Please customize this form to suit your research requirements. The form will be read by a machine. Therefore it is important to use blue or black ballpoint pen and write clearly. We offer our software for free to help stop this pandemic as soon as possible. Reach out to support@papersurvey.io to obtain a free licence.
  5. 2. Stuffy nose / runny nose
  6. 2. Diabetes type 1
  7. Recipient's name
  8. 3. Sore throat
  9. 3. Diabetes type 2
  10. Recipient's name
  11. 4. Cough
  12. 4. Other lung disease
  13. Date of Birth
  14. 5. Shortness of breath
  15. 5. Severe overweight
  16. Age
  17. 6. Chest pain
  18. 6. Cardiovascular disease
  19. Ethnicity
  20. 7. Fever below 39.0
  21. 7. Kidney disease
  22. During the past 12 months have you had swine influenza or other influenza-like illness?
  23. 8. Fever of 39.0 or higher
  24. 8. Impaired immune system
  25. Mark which symptoms you had and how many days they lasted.
  26. 9. Fever (not measured)
  27. 10. Convulsions
  28. Do you have one or more of the following diseases / conditions?
  29. 11. Other convulsions
  30. Have you had a flu vaccination within the last nine months?
  31. 12. Joint pain
  32. How many people you were in contact (in person) with?
  33. 13. Muscle pain
  34. **After** the Coronavirus diagnosis, how many people you were in contact (in person) with?
  35. 14. Vomiting, diarrhoea
  36. How many days did it take until you have recovered?
  37. 15. Ear infection
  38. Please describe how you are feeling Today
  39. 16. Pneumonia
  40. Office Use Only
  41. Doctor's Signature
  42. Date discharged


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