Date of birth Required
Address (as per GP records) Required

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 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


At rest
Changing position e.g. from lying to sitting or sitting to lying
On dressing yourself
On walking up a flight of stairs

Cough/ throat sensitivity/ voice change

Cough/ throat sensitivity
Change of voice

Fatigue (tiredness not improved by rest)

Fatigue levels in your usual activities


Altered smell
Altered taste


Chest pain
Joint pain
Muscle pain
Abdominal pain


Problems with concentration
Problems with memory
Problems with planning

Palpitations/ dizziness

Palpitations in certain positions, activity or at rest
Dizziness in certain positions, activity or at rest

Post-exertional malaise (worsening of symptoms)

Crashing or relapse hours or days after physical, cognitive or emotional exertion

Anxiety/ mood

Feeling anxious
Feeling depressed
Having unwanted memories of your illness or time in hospital
Having unpleasant dreams about your illness or time in hospital
Trying to avoid thoughts or feelings about your illness or time in hospital


Sleep problems, such as difficulty falling asleep, staying asleep or oversleeping

Functional ability


Difficulty with communication/word finding difficulty/understanding others

Walking or moving around

Difficulties with walking or moving around

Personal care

Difficulties with personal tasks such as using the toilet or getting washed and dressed

Other activities of Daily Living

Difficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping

Social role

Problems with socialising/interacting with friends* or caring for dependants *related to your illness and not due to social distancing/lockdown measures

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.

Overall health


Has your COVID-19 illness affected your work?

Partner/family/carer Perspective