CORONA VIRUS INFECTION

Fisrst and Last name

Address

• Duhok
• Zakho
• Akre
• Sumel
• Amedi

Age (Year)

• 20-25
• 25-30
• 30-35
• 35-40
• 40-50

Gender

• Male
• Female

Have you been infected with Covid-19

• Yes
• No

Date of infection

How many time have you been infected with Covid-19
(undefined = 0, undefined = 4)

• 0
• 1
• 2
• 3
• 4

Severity of your infection

• Mild
• Moderate
• Severe

Past medical history

Are you working in hospital

• Yes
• No