Post-COVID Questionnaire

This form is designed to review your symptoms post-COVID, and compare your health prior to testing positive.

Client Details

client_id

Date *

At the time of completing this questionnaire, how many weeks post-COVID (day of positive result) are you? *

Pre-COVID

Pre-COVID, how would you rate the following aspects of your health.

0 - of no concern at all

10 - severely impacting health and quality of life

1. Breathlessness *

2. Airways (upper respiratory) *

3. Chest pain *

4. Voice *

5. Swallowing *

6. Appetite *

7. Mobility *

8. Fatigue levels *

9. Sleep *

10. Personal care *

11. Continence *

12. Ability to carry out usual activities *

13. Pain *

14. Cognition *

15. Mental health *

16. Menopause symptoms *

17. Overall health *

18. Employment *

Your COVID Symptoms

While testing positive, what COVID symptoms did you experience? *

Mouth ulcersHeadacheDiarrhoeaCoughRunny noseAbdominal painMuscle achesFatigueCognitive fogChest painBreathlessnessOther

You selected other. Could you please list what other symptoms you experienced. *

Post-COVID

Post-COVID, how would you rate the following aspects of your health.