COVID-19 Convalescent Plasma Questionnaire
Please complete this form only if you have a documented COVID positive test
Do you have a documented positive COVID-19 test?
*
Yes
No
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COVID-19 Convalescent Plasma Questionnaire
This form is for those with a documented COVID positive result only. Thank you.
Back
Next
COVID-19 Convalescent Plasma Questionnaire
Please complete this form only if you have adocumented COVID positive test
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone number
*
-
Area Code
Phone Number
Current city of residence
*
What was the date of testing?
*
-
Month
-
Day
Year
Date
Do you have the results?
*
Yes
No
Do you have a repeat COVID-19 test that is negative?
*
Yes
No
N/A
What was the date of testing?
*
-
Month
-
Day
Year
Date
Do you have the results?
*
Yes
No
What was the approximate date of resolution of your major symptoms (Fever, Cough, Shortness of Breath)?
*
-
Month
-
Day
Year
Date
For female donors: have you ever been pregnant?
*
Yes
No
N/A
What is your blood group?
*
A
B
AB
O
Unknown
What medications do you take?
*
In the last 12 months have you traveled outside of the United States or Canada?
*
Yes
No
List all countries you traveled to
*
Start date of travel?
*
-
Month
-
Day
Year
Date
End date of travel?
-
Month
-
Day
Year
Date
Have you donated blood within the last eight weeks?
*
Yes
No
Do you have any history of heart or lung disease?
*
Yes
No
Would you be willing to let the Baylor College of Medicine team contact you in the future regarding any COVID-19 related research studies?
*
Yes
No
Submit
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