InspectIR Systems, LLC Anonymous Trial Questionnaire Thank you for participating in the InspectIR Systems, LLC breathalyzer trial. Prior to testing, please complete the anonymous survey below. Please provide accurate answers as this is the key to successful trials. The information provided will be anonymous & will not be used for any purpose other than the performance of the agreed upon test. At completion of the questionnaire, upon submit, you will be assigned a random code. Please keep this code as it will be necessary to begin the testing process. DISCLAIMER: This test has not been reviewed by the FDA. Negative results do not preclude acute SARS-CoV-2 infection. If infection is suspected, direct testing for SARS-CoV-2 is necessary. Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as HKU1, NL63, OC43, or 229E.Height*Please enter a number from 1 to 500.FeetHeight*InchesWeight (lbs)*Please enter a number from 1 to 500.Ethnicity*Gender*MaleFemaleNicotine User*YesNoNicotine Details*Daily Vitamin ?*YesNoVitamin Details*Have You Traveled Internationally in the Last 14 Days?SelectYesNoHave You Come Into Close Contact With a Laboratory Confirmed Case of COVID-19?SelectYesNoDo You Have or Have you Had a Fever in the Last 3 Days?SelectYesNoDo You Currently Have Trouble Breathing?SelectYesNoPrescription Meds*YesNoPlease list the prescrptions with dosage amounts*NameDosage Amount Recreational Drugs*YesNoPlease list the recreational drugs with dosage amounts*NameDosage Amount Thank you for your participation! Click ‘Submit’ below to receive your random code and begin testing. Unique ID