Full name (as it is on your medical records)
* Required
Date of birth
* Required
Date
Address line 1
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Postcode
* Required
NHS number (If known)
Date form completed
Date
Please select one of the options below. Are you completing this for a..
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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
Breathlessness
At rest (now)
0 1 2 3
At rest (pre-Covid)
0 1 2 3
Changing position e.g. from lying to sitting or sitting to lying (now)
0 1 2 3
Changing position e.g. from lying to sitting or sitting to lying (pre-Covid)
0 1 2 3
On dressing yourself (now)
0 1 2 3
On dressing yourself (pre-Covid)
0 1 2 3
On walking up a flight of stairs (now)
0 1 2 3
On walking up a flight of stairs (pre-Covid)
0 1 2 3
Cough/ throat sensitivity/ voice change
Cough/ throat sensitivity (now)
0 1 2 3
Cough/ throat sensitivity (pre-Covid)
0 1 2 3
Change of voice (now)
0 1 2 3
Change of voice (pre-Covid)
0 1 2 3
Fatigue (tiredness not improved by rest)
Fatigue levels in your usual activities (now)
0 1 2 3
Fatigue levels in your usual activities (pre-Covid)
0 1 2 3
Smell/taste
Altered smell (now)
0 1 2 3
Altered smell (pre-Covid)
0 1 2 3
Altered taste (now)
0 1 2 3
Altered taste (pre-Covid)
0 1 2 3
Pain/discomfort
Chest pain (now)
0 1 2 3
Chest pain (pre-Covid)
0 1 2 3
Joint pain (now)
0 1 2 3
Joint pain (pre-Covid)
0 1 2 3
Muscle pain (now)
0 1 2 3
Muscle pain (pre-Covid)
0 1 2 3
Abdominal pain (now)
0 1 2 3
Abdominal pain (pre-Covid)
0 1 2 3
Cognition
Problems with concentration (now)
0 1 2 3
Problems with concentration (pre-Covid)
0 1 2 3
Problems with memory (now)
0 1 2 3
Problems with memory (pre-Covid)
0 1 2 3
Problems with planning (now)
0 1 2 3
Problems with planning (pre-Covid)
0 1 2 3
Palpitations in certain positions, activity or at rest (now)
0 1 2 3
Palpitations in certain positions, activity or at rest (pre-Covid)
0 1 2 3
Dizziness in certain positions, activity or at rest (now)
0 1 2 3
Dizziness in certain positions, activity or at rest (pre-Covid)
0 1 2 3
Palpitations/ dizziness Post-exertional malaise (worsening of symptoms)
Crashing or relapse hours or days after physical, cognitive or emotional exertion (now)
0 1 2 3
Crashing or relapse hours or days after physical, cognitive or emotional exertion (pre-Covid)
0 1 2 3
Anxiety/ mood
Feeling anxious (now)
0 1 2 3
Feeling depressed (now)
0 1 2 3
Feeling anxious (pre-Covid)
0 1 2 3
Having unwanted memories of your illness or time in hospital (now)
0 1 2 3
Having unwanted memories of your illness or time in hospital (pre-Covid)
0 1 2 3
Having unpleasant dreams about your illness or time in hospital (now)
0 1 2 3
Having unpleasant dreams about your illness or time in hospital (pre-Covid)
0 1 2 3
Trying to avoid thoughts or feelings about your illness or time in hospital (now)
0 1 2 3
Trying to avoid thoughts or feelings about your illness or time in hospital (pre-Covid))
0 1 2 3
Sleep
Sleep problems, such as difficulty falling asleep, staying asleep or oversleeping (now)
0 1 2 3
Sleep problems, such as difficulty falling asleep, staying asleep or oversleeping (pre-Covid)
0 1 2 3
Functional ability
Communication
Difficulty with communication/word finding difficulty/understanding others (now)
0 1 2 3
Difficulty with communication/word finding difficulty/understanding others (pre-Covid)
0 1 2 3
Walking or moving around
Difficulties with walking or moving around (now)
0 1 2 3
Difficulties with walking or moving around (pre-Covid)
0 1 2 3
Personal care
Difficulties with personal tasks such as using the toilet or getting washed and dressed (now)
0 1 2 3
Difficulties with personal tasks such as using the toilet or getting washed and dressed (pre-Covid)
0 1 2 3
Difficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping (now)
0 1 2 3
Difficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping (pre-Covid)
0 1 2 3
Other activities of Daily Living
Social role
Problems with socialising/interacting with friends* or caring for dependants *related to your illness and not due to social distancing/lockdown measures (now)
0 1 2 3
Problems with socialising/interacting with friends* or caring for dependants *related to your illness and not due to social distancing/lockdown measures (pre-Covid)
0 1 2 3
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
Any 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.
Overall health (now)
0 1 2 3 4 5 6 7 8 9 10
Overall health (pre-Covid)
0 1 2 3 4 5 6 7 8 9 10
Employment
Occupation
Has your Covid-19 illness affected your work?
Any other comments/concerns:
Partner/family/carer Perspective
This is space for your partner, family or carer to add anything from their perspective
