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.
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:
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.
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.