The purpose of this questionnaire is to find out more about your current problems following Covid-19 illness. Your responses will be recorded in your clinical notes.

We will use this information to monitor your symptoms, offer treatments and assess response to treatment.

This questionnaire will take around 15 minutes. If there are any topics you don’t want to talk about you can choose not to respond.

Date of birth Required
Date form completed
Please select one of the options below. Are you completing this for a.. Required

Symptom Severity

Please answer the questions below to the best of your knowledge. 'Now' refers to how you feel now/this week (last 7 days).

"Pre-COVID" refers to how you were feeling prior to contracting the illness. If you are unable to recall this, just state 'don’t know'

Rate the severity of each problem on a scale of 0-3:

  • 0 = None; no problem
  • 1 = Mild problem; does not affect daily life
  • 2 = Moderate problem; affects daily life to a certain extent
  • 3 = Severe problem; affects all aspects of daily life; life-disturbing


Cough/ throat sensitivity/ voice change

Fatigue (tiredness not improved by rest)




Palpitations/ dizziness

Post-exertional malaise (worsening of symptoms)

Anxiety/ mood


Functional ability


Walking or moving around

Personal care

Other activities of Daily Living

Social role

Other symptoms

Please select any of the following symptoms you have experienced since your illness in the last 7 days. Please also select any previous problems that have worsened for you following your illness.

Other symptoms

Overall Health

How good or bad is your health overall in the last 7 days?

For this question, a score of 10 means the BEST health you can imagine. 0 means the WORST health you can imagine.


Has your Covid-19 illness affected your work?

Partner/family/carer Perspective