Personal Risk

This section will evaluate whether you're at risk from complications from COVID-19 if you were to be infected.

Do you have any chronic medical conditions?

  Yes
  No

What chronic conditions do you have?

1. Chronic kidney disease:
2. Organ or bone marrow transplant:
3. Active hepatitis B infection:
4. Chronic liver disease:
5. Active hepatitis B infection:
6. Any cardiovascular/heart disease including high blood pressure:
7. Diabetes:
8. Any chronic lung disease or condition, including asthma, COPD/chronic emphysema or interstitial lung disease (such as pneumonitis or pulmonary fibrosis):
9. Blood disorders such as sickle cell anemia:
10. Metabolic/mitochondrial disorders:
11. Neurologic/neurodevelopmental conditions including stroke, intellectual disability, moderate to severe neurodevelopmental delay and neuromuscular diseases:
12. Any immunocompromising diseases or medications (diseases or medications that weaken your immune system):

Are you over the age of 60?

  Yes
  No

Do you, or have you ever, smoked?

  Yes
  No

If applicable, are you pregnant or have you been pregnant in the last two weeks?

  Yes
  No

Symptoms Evaluation

This section will to evaluate any of your symptoms

Do you have any of the following symptoms?

1. Fever (temperature >100.4 F or 38 C or feeling like you have a fever):
2. New or unusual cough in the past 7 days:
3. New or unusual difficulty breathing in the past 7 days (e.g., difficulty completing a sentence without gasping for air, or needing to stop to catch breath when walking across a room):
4. Feeling lightheaded, like you may pass out (faint):
5. Confusion or an inability to wake up (despite yelling / shaking):
6. None of the above:

Have you had a fever of 104 degrees or higher?

  Yes
  No

Is it responding (coming down to 102 degrees or lower) with Tylenol/acetaminophen?

  Yes
  No

Do you feel that your cough has gotten worse over the past 24 hours?

  Yes
  No

Are you coughing up more than a teaspoon of blood?

  Yes
  No

Compared to when you are not sick, how would you rate your breathlessness at rest?

  None     Minimal     Moderate     severe  

Are you experiencing any unusual confusion?

  Yes
  No

Have you passed out (fainted)?

  Yes
  No

Are your light-headedness symptoms worsening in the past 24 hours?

  Yes
  No

Personal Details

Kindly provide your personal details

1. Enter your first name

2. Enter your last name

3. Enter your other names

4. Enter your phone number

5. Enter your County of residence

6. Enter your Subcounty of residence

7. Enter your organization of intitution e.g Tom Mboya University College

Do you confirm that data you have entered is accurate?

  Yes (Click here for your evaluation report)
  No