Personalized Pandemic Risk Profile

Under 18
18–29
30–49
50–64
65–74
75+
Prefer not to answer

Male
Female
Other / Prefer not to say

Pregnant
Breastfeeding
Both
Neither
Prefer not to answer

Obesity
Diabetes
Heart disease or hypertension
Chronic lung disease (e.g., asthma, COPD)
Immunocompromised (e.g., cancer, transplant)
No known conditions
Prefer not to answer

Yes, I live with high-risk individuals
No
Unsure / Prefer not to answer

Personal vehicle
Public transportation (bus/train/subway)
Rideshare / Taxi
Bicycle / Walking
Prefer not to answer

Depression or anxiety
Alcohol or drug addiction
None of the above
Prefer not to answer

Heterosexual
Homosexual
Bisexual
Other / Prefer not to say

History of intravenous (IV) drug use
Hemophilia or blood disorder
None of the above
Prefer not to answer

Democrat
Republican
Independent
Other / Prefer not to say

Location:
SelectIndoorsOutdoorsBoth

Estimated number of people:

Select disease:
Select diseaseCOVID-19Influenza (Flu)HPVHepatitis BOther

Vaccination status:
Not vaccinated
Partially vaccinated
Fully vaccinated including boosters
Don’t know / Prefer not to answer

Date of last vaccine dose (if known):

Have you had a confirmed past infection of this disease?
Yes
No
Don’t know / Prefer not to answer

Approximate infection date(s) (if known):

Severity of prior infection:
Mild or asymptomatic
Moderate illness
Severe illness/hospitalization
Unknown / Prefer not to answer

Symptoms you are experiencing (select all that apply):
Fever or chills
Cough
Shortness of breath
Rash or skin lesions
Fatigue or muscle aches
Loss of taste or smell
None of the above
Prefer not to answer

Close contact with confirmed/suspected case (past 14 days):
Yes
No
Prefer not to answer / Unsure

Occupation category:
Select oneHealthcare / First responderRetail or service industryEducation / SchoolFood service / RestaurantDelivery / TransportationOffice / AdministrativeManufacturing / FactoryOther / None

Work environment:
Mostly indoors
Mostly outdoors
Both
Prefer not to answer

Approximate number of close contacts per day at work:

Are masks or protective measures enforced at your workplace?
Yes, enforced
Optional
No policy
Prefer not to answer

Typical ventilation at home:
Windows frequently open / good airflow
Mechanical ventilation / air filtration
Mostly closed windows / limited airflow
Prefer not to answer

Typical ventilation at workplace:
Windows frequently open / good airflow
Mechanical ventilation / air filtration
Mostly closed windows / limited airflow
Prefer not to answer

Have you traveled out of your local area in the last 14 days?
Yes
No
Prefer not to answer

If yes, type of travel (select all that apply):
Domestic
International
Public transport (bus/train/plane)

Planned trips in the next 30 days?
Yes
No
Prefer not to answer

Contact with animals regularly? (Select all that apply)
Pets (cats, dogs, etc.)
Livestock (cattle, poultry, etc.)
Wildlife (birds, rodents, bats)
None
Prefer not to answer

Do you or household members attend or work in: (Select all that apply)
Daycare or preschool
School (student or staff)
Nursing home or long-term care
None
Prefer not to answer

Do you take immunosuppressive meds or have immune conditions? (Select all that apply)
Cancer therapy
Organ transplant recipient
HIV positive
Autoimmune disease treatment
None
Prefer not to answer

This dynamic section adjusts for current epidemic context and disease.

Select (optional)Hispanic or LatinoWhiteBlack or African AmericanAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderOtherPrefer not to say

Reliable access to smartphone or internet?
Yes
No
Prefer not to answer

Reliable transportation to healthcare or vaccination centers?
Yes
No
Prefer not to answer

Allergies or contraindications to vaccines/medications?
Yes
No
Prefer not to answer

If yes, please specify (optional):

Are you a primary caregiver for a child, elderly person, or someone immunocompromised?
Yes
No
Prefer not to answer