How many COVID-19 vaccine dose have you received?

Including yourself, how many people in your household do not ALWAYS practice masking or social distancing outside the home?

Have you had a positive COVID-19 test within the last 10 days?

Have you had any vaccination within the last 14 days?

Have you ever had anaphylaxis (life-threatening allergic reaction)?

Have you had any of the following symptoms within the last 7 days

Do you have any of the following conditions:

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