Post-Covid Wellbeing Screening

Please think about your lifestyle habits and past health history. Please answer each question.
1. Please confirm your contact information *This question is required.
2. What is your gender? *This question is required.
4. Are you currently trying to conceive? *This question is required.
5. Are you currently pregnant? *This question is required.
6. Are you currently breastfeeding? *This question is required.
7. Do you plan on having ANY surgeries in the next 6 weeks (outpatient or inpatient)?  *This question is required.
8. Do you smoke on a regular basis (i.e. multiple times a week or more)? *This question is required.
9. Does anyone in your household smoke on a regular basis? *This question is required.