COVID-19 Baseline Questionnaire

The Huma product offers an easy way of collecting information about a patient's health with respect to COVID-19. Answering all questions and sharing this information will allow Care Teams to make better treatment decisions.

How it works

The first time a patient signs in, they will be prompted to complete the COVID-19 Baseline Questionnaire. In subsequent responses, they will answer questions about tests and symptoms of COVID-19 over the past month. Care teams can view new and historical results in the Huma Portal and concerning scores will be flagged for attention.

In the Patient Summary, care teams will be able to see all historical data in graph or table form.

The COVID-19 Baseline Questionnaire contains 30 questions:

Questions

Question 1: What is your weight, in kgs?

Provide a numeric answer

Question 2: What is your sex?

Select one of the following

Male
Female

Question 3: Are you pregnant?

Answer yes or no

Question 4: Have you had a test for COVID-19?

Answer yes or no

Question 5: Did you test positive for COVID-19?

Select one of the following

Yes
No
Waiting for my results

Question 6: What is your blood type?

Select one of the following

O-positive
O-negative
A-positive
A-negative
B-positive
B-negative
AB-positive
AB-negative
Unknown

Question 7: Have you ever smoked?

Select one of the following

Yes, I still do
Yes, but I quit
No, I have never smoked

Question 8: Roughly how many cigarettes do you smoke a day?

Select one of the following

1-10
10-20
> 20

Question 9: How many years have you been a smoker?

Select one of the following

Less than a year
1 to 5 years
6 to 10 years
11 to 15 years
More than 15 years

Question 10: How long ago did you quit smoking?

Select one of the following

Less than a year
1 to 5 years
6 to 10 years
11 to 15 years
More than 15 years

Question 11: Have you ever vaped?

Select one of the following

Yes, I still do
Yes, but I quit
No, I have never vaped

Question 12: How often do you vape?

Select one of the following

Rarely
Occasionally
Often
Regularly

Question 13: How long ago did you quit?

Select one of the following

Less than a year
1 to 5 years
6 to 10 years

Question 14: Overall, how would you rate your health?

Select one of the following

Poor
Fair
Good
Excellent

Question 15: Do you have any pre-existing conditions?

Answer yes or no

Question 16: Do you have any of the following conditions?

Choose multiple of the following

Asthma
COPD
Other chronic lung diseases
Coronary artery disease
Heart failure
Other heart conditions
High blood pressure
Diabetes
Chronic kidney disease
Chronic liver disease
Cancer
Autoimmune conditions
HIV
Others

Question 17: Please enter the existing condition that you have?

Write a descriptive answer

Question 18: Are you on any regular medications? Please list the medications you are on

Write a descriptive answer

Question 19: Are there any conditions that run in your family? Please list the conditions if any

Write a descriptive answer

Question 20: Do you have any allergies?

Answer yes or no

Question 21: Please list your allergies

Write a descriptive answer

Question 22: In the last 14 days have you experienced or still experiencing any symptoms?

Answer yes or no

Question 23: Please select all the symptoms that you have experienced or currently experiencing

Choose multiple of the following

Fever
Cough
Shortness of breath
Tiredness
Muscle aches
Runny nose
Blocked nose
Sore throat
Nausea
Vomiting
Diarrhoea
Headache
Night sweats
Chest pain or tightness
Dizziness
Loss of consciousness
Heart palpitations
Loss of appetite
Loss of smell
Loss of taste
Other

Question 24: Please enter the other symptoms

Write a descriptive answer

Question 25: When did your symptoms start?

Select a date

Question 26: In the past 14 days or since first onset of your symptoms have you

Select one of the following

Had close contact with an individual who was confirmed with the diagnosis of COVID-19
Had close contact with an individual with signs or symptoms of fever, cough, chest infection
Worked in or attended to a healthcare facility where confirmed COVID-19 infections have been reported
None of the above apply to me

Question 27: Please select that best describes your living situation

Select one of the following

I live alone
I live with family
I live with friends/partner
I live with a carer

Question 28: Have you travelled in the past 14 days?

Answer yes or no

Question 29: Please list all countries including any stopovers or connections for any length of time in the last 14 days.

Write a descriptive answer

Question 30: How are you feeling right now? Are you so ill that you've stopped doing all of your usual daily activities, such as watch TV, use your phone, read or get out of bed?

Select one of the following

Yes, I've stopped doing everything I usually do
I feel unwell but can still do some of my usual daily activities
No, I feel well enough to do most of my usual daily activities

How it works​

Questions​

Question 1: What is your weight, in kgs?​

Question 2: What is your sex?​

Question 3: Are you pregnant?​

Question 4: Have you had a test for COVID-19?​

Question 5: Did you test positive for COVID-19?​

Question 6: What is your blood type?​

Question 7: Have you ever smoked?​

Question 8: Roughly how many cigarettes do you smoke a day?​

Question 9: How many years have you been a smoker?​

Question 10: How long ago did you quit smoking?​

Question 11: Have you ever vaped?​

Question 12: How often do you vape?​

Question 13: How long ago did you quit?​

Question 14: Overall, how would you rate your health?​

Question 15: Do you have any pre-existing conditions?​

Question 16: Do you have any of the following conditions?​

Question 17: Please enter the existing condition that you have?​

Question 18: Are you on any regular medications? Please list the medications you are on​

Question 19: Are there any conditions that run in your family? Please list the conditions if any​

Question 20: Do you have any allergies?​

Question 21: Please list your allergies​

Question 22: In the last 14 days have you experienced or still experiencing any symptoms?​

Question 23: Please select all the symptoms that you have experienced or currently experiencing​

Question 24: Please enter the other symptoms​

Question 25: When did your symptoms start?​

Question 26: In the past 14 days or since first onset of your symptoms have you​

Question 27: Please select that best describes your living situation​

Question 28: Have you travelled in the past 14 days?​

Question 29: Please list all countries including any stopovers or connections for any length of time in the last 14 days.​

Question 30: How are you feeling right now? Are you so ill that you've stopped doing all of your usual daily activities, such as watch TV, use your phone, read or get out of bed?​

How it works

Questions

Question 1: What is your weight, in kgs?

Question 2: What is your sex?

Question 3: Are you pregnant?

Question 4: Have you had a test for COVID-19?

Question 5: Did you test positive for COVID-19?

Question 6: What is your blood type?

Question 7: Have you ever smoked?

Question 8: Roughly how many cigarettes do you smoke a day?

Question 9: How many years have you been a smoker?

Question 10: How long ago did you quit smoking?

Question 11: Have you ever vaped?

Question 12: How often do you vape?

Question 13: How long ago did you quit?

Question 14: Overall, how would you rate your health?

Question 15: Do you have any pre-existing conditions?

Question 16: Do you have any of the following conditions?

Question 17: Please enter the existing condition that you have?

Question 18: Are you on any regular medications? Please list the medications you are on

Question 19: Are there any conditions that run in your family? Please list the conditions if any

Question 20: Do you have any allergies?

Question 21: Please list your allergies

Question 22: In the last 14 days have you experienced or still experiencing any symptoms?

Question 23: Please select all the symptoms that you have experienced or currently experiencing

Question 24: Please enter the other symptoms

Question 25: When did your symptoms start?

Question 26: In the past 14 days or since first onset of your symptoms have you

Question 27: Please select that best describes your living situation

Question 28: Have you travelled in the past 14 days?

Question 29: Please list all countries including any stopovers or connections for any length of time in the last 14 days.

Question 30: How are you feeling right now? Are you so ill that you've stopped doing all of your usual daily activities, such as watch TV, use your phone, read or get out of bed?