Post (Long) COVID-19 Syndrome Questionnaire

This questionnaire is for people in Derbyshire that have had either a confirmed diagnosis of coronavirus disease (COVID-19) or have experienced coronavirus symptoms, such as a high temperature, persistent cough, loss of taste and smell.

This questionnaire is to find out if you are continuing to experience diagnosed coronavirus or suspected coronavirus symptoms. We will add any information you provide in your confidential clinical notes, and forward on to the Post (Long) COVID-19 Assessment Service, where Clinicians from different professions will assess you and will work together to ensure you receive the most appropriate care for your symptoms. You may also be referred to other services to provide additional support and treatment for your symptoms.

The information you provide will be stored as per data protection regulations, and used for purposes of clinical assessment only (for use only by Clinicians involved in your care), and will be kept in your patient records.

Post (Long) COVID-19 Syndrome Questionnaire

Post (Long) COVID-19 Syndrome Questionnaire

Patient Details

Please use date format DD/MM/YYYY
Do you agree to share the information you provide with the Post (Long) COVID-19 Syndrome Assessment Service today? *

Questionnaire

Please select the description for each question that best describes how you currently feel so that a clinician can refer you to the appropriate services for your symptoms.

Breathing

Normal
Mild
Moderate
Severe

Mobility/Activity

Normal
Mild
Moderate
Severe

Energy Levels

Normal
Mild
Moderate
Severe

Mood

Normal
Mild
Moderate
Severe

What was your health like before you had Covid, some examples are below to assist you:

  • I did not have any restrictions on my life
  • I had some restrictions, e.g. mobility
  • I had existing restrictions on my life
Are you living with a long term health condition(s)? *
Were you admitted to hospital with a diagnosis of Covid, or were you admitted to hospital with Covid like symptoms? *
Were you re-admitted to hospital? *
Have you used any other health services since discharge from hospital for Covid like symptoms (for example, your GP?) *

How have you been affected by Coronavirus?

Breathlessness

On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you: (Please leave blank if you do not perform this activity)

At rest?

Now: *
Before Covid: *

On dressing yourself?

Now:
Before Covid:

On walking up a flight of stairs?

Now:
Before Covid:

Cardiac (heart related) chest pain (angina)

Do you have any chest discomfort, shortness of breath, cardiac chest pains or symptoms of angina? *
Is this new (following Covid) or old? *
How is it affecting you in activities of daily living on the scale of 0-10 below (0 being no impact, 10 being significant impact): *

Palpitations or feeling of your own heart flutters

Do you have symptoms of heart palpitations/flutters? *
Is this new (following Covid) or old? *
How is it affecting you in activities of daily living on the scale of 0-10 below (0 being no impact, 10 being significant impact): *

Stroke

Have you had a stroke since having Covid like symptoms? *
Has a stroke had an impact on your ability to carry out your normal daily activities? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Throat/breathing problems

Have you developed any changes in the sensitivity of your throat such as troublesome cough or noisy breathing? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Voice

Have you or your family noticed any changes to your voice such as difficulty being heard, changed quality of the voice, your voice tiring by the end of the day or an inability to change the pitch of your voice? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Swallowing

Are you having difficulties eating, drinking or swallowing such as coughing, choking or avoiding any food or drinks? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Nutrition (Eating)

Are you or your family concerned that you have ongoing weight loss or any ongoing nutritional concerns as a result of Covid-19? *
Please rank your appetite or interest in eating on a scale of 0-10 since Covid-19 (0 being same as usual/no problems, 10 being very severe problems/reduction): *

Mobility (Movement)

On a 0-10 scale, how severe are any problems you have in walking about, for example, 0 means you have no problems, 10 means you are completely unable to walk about.

Now: *
Before Covid: *

Fatigue or Exhaustion

Do you become fatigued (extremely tired) more easily compared to before your illness? *

How severely does this affect your mobility (movement), personal care, activities or enjoyment of life? (0 being not affecting, 10 being very severely impacting)

Now: *
Before Covid: *

Personal Care

On a 0-10 scale, how severe are any problems you have in personal care such as washing and dressing yourself? (0 means you have no problems, 10 means you are completely unable to do your personal care)

Now: *
Before Covid: *

Continence (control of bowel or bladder)

Since your illness are you having any new problems with:

Controlling your bowel? *
Controlling your bladder? *

Usual Activities

On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as household chores, leisure activities, work or study?
(0 means you have no problems, 10 means you are completely unable to do your usual activities)

Now: *
Before Covid: *

Pain / Discomfort

On a 0-10 scale, how severe is any pain or discomfort you have? (0 means you have no pain or discomfort, 10 means you have extremely severe pain)

Now: *
Before Covid: *

Cognition (the ability to think, memory, clarity of thought, how we organise ourselves, how we process things)

Since your illness have you had new or worsened difficulty with:

Concentrating? *
Short term memory? *

Cognitive-Communication (how our ability to think and organise our thoughts impacts on how we are able to communicate with others both verbally and non-verbally)

Have you or your family noticed any change in the way you communicate with people, such as making sense of things people say to you, putting thoughts into words, difficulty reading or having a conversation? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Anxiety (feeling worried or nervous)

On a 0-10 scale, how severe is the anxiety you are experiencing? (0 means you are not anxious, 10 means you are extremely anxious)

Now: *
Before Covid: *

Depression (sadness or lack of interest)

On a 0-10 scale, how severe is the depression you are experiencing? (0 means you are not depressed, 10 means you have extreme depression)

Now: *
Before Covid: *

Post Traumatic Stress Disorder (PTSD (an anxiety disorder caused by very stressful, frightening or distressing events)

Have you had any unwanted memories of your illness or hospital admission whilst you are awake, so not including dreams? *
How much do these memories bother you? *
Have you had any unpleasant dreams about your illness or hospital admission? *
How much do these dreams bother you? *
Have you tried to avoid thoughts or feelings about your illness or hospital admission? *
How much effort do you make to avoid these thoughts or feelings? *
Are you currently having thoughts about harming yourself in any way? *

Overall Health

How poor do you feel your overall health is? (10 means the worst health you can imagine. 0 means the best health you can imagine)

Now: *
Before Covid: *

Vocation (Employment)

Has your illness affected your ability to do your usual work?

Family/Carers Views

Additional Information