Testing Form | InspectIR Systems

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.

Feet

Height*

Inches

Weight (lbs)*

Please enter a number from 1 to 500.

Ethnicity*

Gender*

Nicotine User*

Nicotine Details*

Daily Vitamin ?*

Vitamin Details*

Have You Traveled Internationally in the Last 14 Days?

Have You Come Into Close Contact With a Laboratory Confirmed Case of COVID-19?

Do You Have or Have you Had a Fever in the Last 3 Days?

Do You Currently Have Trouble Breathing?

Prescription Meds*

Please list the prescrptions with dosage amounts*

Name	Dosage Amount

Recreational Drugs*

Please list the recreational drugs with dosage amounts*

Name	Dosage Amount

Thank you for your participation! Click ‘Submit’ below to receive your random code and begin testing.

Unique ID

InspectIR Systems, LLC Anonymous Trial Questionnaire