{"flag":true,"survey":{"guid":"57e53256-c0ed-4b3b-9695-ac7f07b9c208","email":"templates@surveyol.com","title":"COVID-19 Patient Survey ","centerAligned":false,"dirty":false,"createdDate":"2020-05-11T02:26:45.9251798","modifiedDate":"2020-05-11T02:26:45.9251798","activePageIndex":0,"pages":[{"guid":"0c6a90fd-056a-4511-a885-37f03cd1ff1a","title":null,"titleDisplay":"[Page 1]","description":null,"centerAligned":false,"dirty":false,"pageIndex":0,"activeQuestionIndex":4,"deleted":false,"deletedDate":null,"questions":[{"guid":"265ec2ce-ff8f-48d9-ba67-9497fdbcc7dd","questionType":"Multiple Choice","title":"Have you experience any of the following symptoms in the past 2 weeks?","titleDisplay":"Have you experience any of the following symptoms in the past 2 weeks?","question":"{\"title\":\"Have you experience any of the following symptoms in the past 2 weeks?\",\"multiSelect\":true,\"choices\":[\"Fever\",\"Dry cough\",\"Shortness of breath\",\"Decreased sense of smell/taste\",\"Other flu-like symptoms\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"requireAnswer\":true}","questionIndex":0,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"Have you experience any of the following symptoms in the past 2 weeks?","requireAnswer":true,"choices":["Fever","Dry cough","Shortness of breath","Decreased sense of smell/taste","Other flu-like symptoms"],"multiSelect":true,"addOtherAnswerOption":false,"addOtherLabel":"","addOtherBlankMessage":""}},{"guid":"afe6d002-02c3-4b75-8de0-65b61a00cf06","questionType":"Multiple Choice","title":"Have you ever been tested for Coronavirus (COVID-19)?","titleDisplay":"Have you ever been tested for Coronavirus (COVID-19)?","question":"{\"title\":\"Have you ever been tested for Coronavirus (COVID-19)?\",\"multiSelect\":false,\"choices\":[\"Yes\",\"No\",\"Don’t know\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"requireAnswer\":true}","questionIndex":1,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"Have you ever been tested for Coronavirus (COVID-19)?","requireAnswer":true,"choices":["Yes","No","Don’t know"],"multiSelect":false,"addOtherAnswerOption":false,"addOtherLabel":"","addOtherBlankMessage":""}},{"guid":"58423032-6659-4ccd-a25b-b08a4d40d2d8","questionType":"Multiple Choice","title":"Do you have any ongoing medical condition that might put you at a higher risk for severe illness from Coronavirus (COVID-19)?","titleDisplay":"Do you have any ongoing medical condition that might put you at a higher risk for severe illness from Coronavirus (COVID-19)?","question":"{\"title\":\"Do you have any ongoing medical condition that might put you at a higher risk for severe illness from Coronavirus (COVID-19)?\",\"multiSelect\":true,\"choices\":[\"Cardiovascular conditions\",\"Chronic lung disease\",\"Obesity\",\"Diabetes\",\"A weakened immune system\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"requireAnswer\":true}","questionIndex":2,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"Do you have any ongoing medical condition that might put you at a higher risk for severe illness from Coronavirus (COVID-19)?","requireAnswer":true,"choices":["Cardiovascular conditions","Chronic lung disease","Obesity","Diabetes","A weakened immune system"],"multiSelect":true,"addOtherAnswerOption":false,"addOtherLabel":"","addOtherBlankMessage":""}},{"guid":"57814038-f180-42e1-9491-bc3fd81cf26e","questionType":"Multiple Choice","title":"During the past week, how often did you wash your hands with soap and water or use hand sanitizer?","titleDisplay":"During the past week, how often did you wash your hands with soap and water or use hand sanitizer?","question":"{\"title\":\"During the past week, how often did you wash your hands with soap and water or use hand sanitizer?\",\"multiSelect\":false,\"choices\":[\"0 times a day\",\"1-6 times a day\",\"More than 6 times a day\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"requireAnswer\":true}","questionIndex":3,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"During the past week, how often did you wash your hands with soap and water or use hand sanitizer?","requireAnswer":true,"choices":["0 times a day","1-6 times a day","More than 6 times a day"],"multiSelect":false,"addOtherAnswerOption":false,"addOtherLabel":"","addOtherBlankMessage":""}},{"guid":"ffdf2945-f9f4-4fae-9b84-ca87561a600a","questionType":"Dropdown","title":"During the past week, how many days did you leave your home?","titleDisplay":"During the past week, how many days did you leave your home?","question":"{\"title\":\"During the past week, how many days did you leave your home?\",\"choices\":[\"0\",\"1\",\"2\",\"3\",\"4\",\"5\",\"6\",\"7\"],\"addOtherAnswerOption\":false,\"addOtherLabel\":\"\",\"addOtherBlankMessage\":\"\",\"requireAnswer\":true}","questionIndex":4,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"During the past week, how many days did you leave your home?","requireAnswer":true,"choices":["0","1","2","3","4","5","6","7"],"addOtherAnswerOption":false,"addOtherLabel":"","addOtherBlankMessage":""}},{"guid":"388a00d1-fdc8-495a-9973-d292cbad1337","questionType":"Comment Box","title":"Do you have any other comments, questions, or concerns?","titleDisplay":"Do you have any other comments, questions, or concerns?","question":"{\"title\":\"Do you have any other comments, questions, or concerns?\",\"requireAnswer\":false}","questionIndex":5,"dirty":false,"deleted":false,"deletedDate":null,"QuestionDetails":{"title":"Do you have any other comments, questions, or concerns?","requireAnswer":false,"answerFormat":null}}]}],"colorTheme":{"guid":"f34e29a6-6c4f-4209-824d-e1992392eed3","name":"Pantone 2020: Classic Blue","isSystem":true,"dirty":false,"accountId":null,"usedCount":0,"profile":{"logoBackColor":"#efefef","titleBackColor":"#0F4C81","titleTextColor":"#ffffff","pageTitleBackColor":"#275D8D","pageTitleTextColor":"#ffffff","backColor":"#efefef","backImage":"","backIcon":"","backSize":"","backSource":"upload","pageBackColor":"#ffffff","pageDescriptionTextColor":"#000000","validationTextColor":"#ff0000","questionPrefixTextColor":"#ff0000","questionTitleTextColor":"#000000","answerTextColor":"#000000","font":"Arial"}},"profile":{"display":{"surveyTitleOn":true,"pageTitlesOn":true,"pageNumbersOn":false,"questionNumbersOn":true,"requiredAsterisksOn":true,"previousButtonsOn":true,"progressBar":{"on":false,"position":null,"type":"question"},"exitLinkOn":false,"oneQuestionAtaTime":false},"footer":{"removeBrandFooter":false,"customFooter":""},"alerts":{"enableDailyAlerts":true,"enableEveryResponseAlerts":false},"logo":{"place":"none","url":null,"source":null,"width":null,"height":null},"choiceRnd":{"type":"off","scope":"all","questions":[],"exceptLast":[]},"questionRnd":{"type":"off","scope":"all","questions":[]},"pageRnd":{"type":"off","scope":"all","pages":[]},"buttons":{"previous":"Previous","next":"Next","done":"Done"},"messages":{"invalidAnswer":"The answer is invalid.","requiredAnswer":"This question requires an answer.","finish":"Thank you for taking this survey.","disqualification":"Thanks for your time! We're sorry you don't qualify for this survey.","closed":"This survey is currently closed. Please contact the author of this survey for further assistance.","alreadyTaken":"You have already taken this survey.","quotaReached":"Thanks for your time! We're sorry the maximum number of responses has been met."},"endPages":{"thankYouRedirectionSeconds":null,"thankYouRedirectUrl":null,"disqualificationRedirectionSeconds":null,"disqualificationRedirectUrl":null,"alreadyTakenRedirectionSeconds":null,"alreadyTakenRedirectUrl":null,"closedRedirectionSeconds":null,"closedRedirectUrl":null,"quotaReachedRedirectionSeconds":null,"quotaReachedRedirectUrl":null},"variables":[],"quota":null,"quotaReached":false},"rules":[],"canManageDesign":false,"canViewDesign":false,"canManageSend":false,"canViewSend":false,"canManageAnalyze":false,"canViewAnalyze":false,"isShared":false,"questionCount":6,"responseCount":0,"collaboratorCount":0,"collectorCount":0,"lastResponseOn":null,"isSample":false},"title":"COVID-19 Patient Survey Template","content":"\r\n<p class=\"template-tip-title\">Coronavirus (COVID-19) Patient Survey Tips</p><p>The coronavirus pandemic (COVID-19) has infected over a million people globally. Many physicians feel they still do not understand the relationship between their patients, the pandemic, the medications used and the associated risks. While many patients with COVID-19 have mild symptoms or are asymptomatic, there is still a strong possibility that a large proportion of these patients could ultimately become ill, especially without the availability today of a vaccine.\r\n</p><p>Many medical offices have set up call centers to reach out to its patients. This proactive approach to see how each patient is doing, especially if they reside in a \"hot spot\" area, is a critical step in gathering information. The confidential survey should ask about each patient's medical history, any relevant symptom(s) that may have recently developed, and whether they have been diagnosed with the virus.\r\n</p><p>In this time of uncertainty and stress, it is also critical your survey offer an open-ended question to allow your patients to share their comments, questions, and concerns.\r\n</p><p>Use our exclusive Corona (COVID-19) patient survey template or create one yourself by just <a href=\"/register\">creating an account</a> or <a href=\"/signin\">signing in</a> to Surveyol.</p>"}