Tell us your Influenza Human story
Have you been diagnosed with Influenza Human? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
Does Influenza Human impact relationships with family or caregivers? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Does Influenza Human impact your daily exercise or other activities? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Does Influenza Human impact your mental health? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Does Influenza Human impact your healthcare costs? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Are you currently looking for a Influenza Human clinical trial? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
First Name
Last Name
Email
Phone (Optional)
Age (Optional)
Postal Code (Optional)
Gender (Optional)
Select One
Male
Female
Transgender Male
Transgender Female
Gender Variant/Non-Conforming
Unspecified
How would you like to be contacted? (Optional)
Select One
Phone Call
SMS
Text
Any
What would you like researchers to know about your experience with Influenza Human? (Optional)
Share my story