SADS Conditions and SARS-CoV-2-Caused COVID-19 Questionnaire

Coronavirus disease 2019 (COVID-19) is a potentially life-threatening respiratory/systemic disease, that is highly contagious due to SARS-CoV-2 (coronavirus), and is a global pandemic. On behalf of the Sudden Arrhythmia Death Syndromes (SADS) Foundation, please take 5 minutes to complete this survey to learn more about if and how our families are being impacted by SARS-CoV-2-COVID-19.

1.Name (optional)

2.Email (Optional)

3.Can we contact you to follow up on this study?

Yes

4.May we contact you to keep you up to date on SADS Foundation activities?

Yes

5.SADS Condition

6.Age

7.Country/State

8.Have you been exposed to a person with a positive SARS-CoV-2 test?

Yes

9.Have you been tested for SARS-CoV-2?

Yes

10.If tested were you,

Positive

Negative

11.Have you had any symptoms of coronavirus caused by COVID-19? Check any that apply

Dry cough

Fever over 100.4°F/38°C

Shortness of breath

Loss of smell and/or taste

Sore throat

GI Symptoms

Other symptoms?

12.If you’ve had symptoms, have you been hospitalized for COVID-19?

Yes

13.If yes, were you:

Hospitalized on regular ward

Admitted to ICU without intubation/ventilator

Admitted to ICU with intubation/ventilation

14.If not, were you told to quarantine at home?

Yes

15.If you were positive or got sick from coronavirus, how long did it take you to recover?

2-5 days

6-10 days

11-14 days

15 or more days

16.If you were treated for COVID-19, what treatments were used:

Supportive care (Tylenol, fluids)

Chloroquine

Hydroxychloroquine

Azithromycin

Plasma therapy

Antiviral (like Remdesivir)

Other (please specify)

17.Tell us what happen to you:

18.Other comments:

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