Health SurveyFor form testing tips, check out our complete guide! Name Gender MALE FEMALE Age Zipcode Email- We email results of the survey. How many Covid-19 Vaccines injections, including boosters, did you receive? 6 5 4 3 2 1 0 How many times did you get diagnosed with Covid-19? 4 3 2 1 0 Did your health improve after taking the Covid-19 Vaccine? Yes No Temporary N/A How would you rate the medical industry performance during Covid-19? Very satisfied Satisfied Neutral Unsatisfied Very Unsatisfied How would you rate the U.S government's performance of managing Covid-19? Very satisfied Satisfied Neutral Unsatisfied Very Unsatisfied How would you rate your overall Health prior to Covid-19? Excellent Good Ok Not good Terrible Have you had any serious illness in 2021 and/or 2022? No Blood Clots Heart Problems Brain Issues Severe Allergic Reaction Other How would you rate your overall Health now? Excellent Good Ok Not good Terrible Has anyone in your family died within a week after taking the Covid-19 Vaccine? Yes No Have you had any adverse effects from the Covid-19 Vaccine? Yes No Do you feel the Covid-19 Vaccine is Helpful Harmful SUBMIT
