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Questionnaire 1/1

For whom are you completing this questionnaire?
You have indicated that you are going to report symptoms for someone else. Have you asked permission from this person to fill out this questionnaire?
Okay. Do not forget to take federal guidelines into account. Be sure to keep your distance from people with symptoms. For example, if you’re filling this out for someone else, go through the questionnaire by phone instead of sitting next to them.
Please select the location where you currently live
What happens to my location data?
Search using street, city or postalcode
What year were you born in?
What is your gender?
Okay, enough about you. Let’s continue with the symptoms. Do you have a fever?
What is a fever?
Do you suffer from a dry cough?
What is a dry cough?
Do you suffer from fatigue?
What is fatigue?
And when you cough, do you cough up thick mucus?
How do I know I am coughing up thick mucus?
Do you experience shortness of breath?
What is shortness of breath?
Do you have pain in your muscles or joints?
What does this mean?
Do you have a sore throat?
What is a sore throat?
Do you have a headache?
What’s a headache?
Do you experience chills?
What are chills?
Do you feel nauseous or have you vomited?
What do you mean?
Are there any other symptoms you’re experiencing?
How many days ago did your first symptoms start?
0
    Which symptom did you discover first?

    You can select a maximum of 2 symptoms. You don’t have to select any symptoms if you don’t remember.

    Have you been in contact with someone who has tested positive for coronavirus?
    Do you (voluntarily) self-quarantine?
    What does “self-quarantine” mean?
    Are you practicing social distancing?
    What does “social distancing” mean?
    How many times a day do you leave your house?
    0 times
      Have you been abroad in the past two weeks? If so, where to?
      Afghanistan
      Albania
      Algeria
      American Samoa
      Andorra
      Angola
      Anguilla
      Antarctica
      Antigua and Barbuda
      Argentina
      Armenia
      Aruba
      Australia
      Austria
      Azerbaijan
      Bahamas (the)
      Bahrain
      Bangladesh
      Barbados
      Belarus
      Belgium
      Belize
      Benin
      Bermuda
      Bhutan
      Bolivia (Plurinational State of)
      Bonaire, Sint Eustatius and Saba
      Bosnia and Herzegovina
      Botswana
      Bouvet Island
      Brazil
      British Indian Ocean Territory (the)
      Brunei Darussalam
      Bulgaria
      Burkina Faso
      Burundi
      Cabo Verde
      Cambodia
      Cameroon
      Canada
      Cayman Islands (the)
      Central African Republic (the)
      Chad
      Chile
      China
      Christmas Island
      Cocos (Keeling) Islands (the)
      Colombia
      Comoros (the)
      Congo (the Democratic Republic of the)
      Congo (the)
      Cook Islands (the)
      Costa Rica
      Croatia
      Cuba
      Curaçao
      Cyprus
      Czechia
      Côte d'Ivoire
      Denmark
      Djibouti
      Dominica
      Dominican Republic (the)
      Ecuador
      Egypt
      El Salvador
      Equatorial Guinea
      Eritrea
      Estonia
      Eswatini
      Ethiopia
      Falkland Islands (the) [Malvinas]
      Faroe Islands (the)
      Fiji
      Finland
      France
      French Guiana
      French Polynesia
      French Southern Territories (the)
      Gabon
      Gambia (the)
      Georgia
      Germany
      Ghana
      Gibraltar
      Greece
      Greenland
      Grenada
      Guadeloupe
      Guam
      Guatemala
      Guernsey
      Guinea
      Guinea-Bissau
      Guyana
      Haiti
      Heard Island and McDonald Islands
      Holy See (the)
      Honduras
      Hong Kong
      Hungary
      Iceland
      India
      Indonesia
      Iran (Islamic Republic of)
      Iraq
      Ireland
      Isle of Man
      Israel
      Italy
      Jamaica
      Japan
      Jersey
      Jordan
      Kazakhstan
      Kenya
      Kiribati
      Korea (the Democratic People's Republic of)
      Korea (the Republic of)
      Kuwait
      Kyrgyzstan
      Lao People's Democratic Republic (the)
      Latvia
      Lebanon
      Lesotho
      Liberia
      Libya
      Liechtenstein
      Lithuania
      Luxembourg
      Macao
      Madagascar
      Malawi
      Malaysia
      Maldives
      Mali
      Malta
      Marshall Islands (the)
      Martinique
      Mauritania
      Mauritius
      Mayotte
      Mexico
      Micronesia (Federated States of)
      Moldova (the Republic of)
      Monaco
      Mongolia
      Montenegro
      Montserrat
      Morocco
      Mozambique
      Myanmar
      Namibia
      Nauru
      Nepal
      Netherlands (the)
      New Caledonia
      New Zealand
      Nicaragua
      Niger (the)
      Nigeria
      Niue
      Norfolk Island
      Northern Mariana Islands (the)
      Norway
      Oman
      Pakistan
      Palau
      Palestine, State of
      Panama
      Papua New Guinea
      Paraguay
      Peru
      Philippines (the)
      Pitcairn
      Poland
      Portugal
      Puerto Rico
      Qatar
      Republic of North Macedonia
      Romania
      Russian Federation (the)
      Rwanda
      Réunion
      Saint Barthélemy
      Saint Helena, Ascension and Tristan da Cunha
      Saint Kitts and Nevis
      Saint Lucia
      Saint Martin (French part)
      Saint Pierre and Miquelon
      Saint Vincent and the Grenadines
      Samoa
      San Marino
      Sao Tome and Principe
      Saudi Arabia
      Senegal
      Serbia
      Seychelles
      Sierra Leone
      Singapore
      Sint Maarten (Dutch part)
      Slovakia
      Slovenia
      Solomon Islands
      Somalia
      South Africa
      South Georgia and the South Sandwich Islands
      South Sudan
      Spain
      Sri Lanka
      Sudan (the)
      Suriname
      Svalbard and Jan Mayen
      Sweden
      Switzerland
      Syrian Arab Republic
      Taiwan (Province of China)
      Tajikistan
      Tanzania, United Republic of
      Thailand
      Timor-Leste
      Togo
      Tokelau
      Tonga
      Trinidad and Tobago
      Tunisia
      Turkey
      Turkmenistan
      Turks and Caicos Islands (the)
      Tuvalu
      Uganda
      Ukraine
      United Arab Emirates (the)
      United Kingdom of Great Britain and Northern Ireland (the)
      United States Minor Outlying Islands (the)
      United States of America (the)
      Uruguay
      Uzbekistan
      Vanuatu
      Venezuela (Bolivarian Republic of)
      Viet Nam
      Virgin Islands (British)
      Virgin Islands (U.S.)
      Wallis and Futuna
      Western Sahara
      Yemen
      Zambia
      Zimbabwe
      Åland Islands
      One last question. What is your email address?

      We only use your email address to send you a link with which you can adjust your answers or let us know when you’re feeling better. We do not store your email address.

      Why do I have to submit my email address?
      I agree that SymptoTrack will save my data in accordance with the privacy policy. privacyvoorwaarden.