UCSD Covid App

First Name Last Name Date of Birth

Complete the following registration form with questions about you and your health

Registration*

First Name Last Name Date of Birth Zip Code How would you like to receive your test recommendations and complete our follow-up survey? Mobile phone

Mobile Phone

Home phone

Home Phone

Personal email

Personal Email

Mail/Paper Copy

Street Address City State

What is your biological sex assigned at birth? Female Male Intersex None of these describe me Prefer not to answer Are you of Hispanic, Latino, or Spanish origin? No, not of Hispanic, Latino, or Spanish origin Yes, of Hispanic, Latino, or Spanish origin Prefer not to answer

Check all that apply
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Another Hispanic, Latino, or Spanish origin
Salvadoran
Dominican
Columbian
Prefer not to answer

Please specify other Hispanic, Latino, or Spanish origin, For example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.

What is your race?
Check all that apply
American Indian or Alaska Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
White
Some Other Race
Prefer not to answer

Check all that apply
Japanese
Filipino
Chinese, except Taiwanese
Korean
Other Asian
Asian Indian
Bangladeshi
Bhutanese
Burmese
Cambodian
Hmong
Indonesian
Laotian
Malaysian
Mongolian
Nepalese
Okinawan
Pakistani
Sri Lankan
Taiwanese
Thai
Vietnamese
Prefer not to answer

Check all that apply
Native Hawaiian
Pacific Islander
Samoan
Tongan
Maori
Fijian
Chamorro
Chuukese
Kosraen
Marshallese
Palauan
Pohnpeian
Yapese
Other Pacific Islander
Prefer not to answer

Specify other origin.

Health *

Have you had any symptoms during the past week? Yes No

Fever or chills? Yes No Shortness of breath or difficulty breathing? Yes No Lack of energy or general tired feeling? Yes No Muscle or body aches? Yes No Headache? Yes No New loss of taste or smell? Yes No Sore throat, congestion or runny nose? Yes No Abdominal Pain? Yes No Skin Rash? Yes No Other? Yes No

When do you plan to take your test? Today Within the next week I'm saving this for when I need it Other

Other:

Have you been in contact with someone diagnosed with COVID-19 in the last 2 weeks? Yes, they live with me Yes, they do NOT live with me No Have you received a COVID-19 vaccine? Yes No Don't know Prefer not to answer Have you ever been tested for COVID-19? Yes No Don't know Prefer not to answer