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COVID and other Pulmonary Diseases Risk Predictor
Name
Email
Cough*
Select option
0 (I never cough)
1
2
3
4
5 (I cough all the time)
Phlegm*
Select option
0 (I have no phlegm in my chest at all)
1
2
3
4
5 (My chest is completely full of phlegm)
Chest Tightness*
Select option
0 (My chest does not feel tight at all)
1
2
3
4
5 (My chest feels very tight)
Breathlessness*
Select option
0 (When I walk up a hill or one flight of stairs I am not breathless)
1
2
3
4
5 (When I walk up a hill or one flight of stairs I am very breathless)
Activities*
Select option
0 (I am not limited doing any activities at home)
1
2
3
4
5 (I am very limited doing any activities at home)
Confidence*
Select option
0 (I am confident leaving my home despite my lung condition)
1
2
3
4
5 (I am not at all confident leaving my home because of my lung condition)
Sleep*
Select option
0 (I sleep soundly)
1
2
3
4
5 (I don't sleep soundly because of my lung condition)
Energy*
Select option
0 (I have lots of energy)
1
2
3
4
5 (I have no energy at all)