Long COVID Assessment

Please complete and submite the following form if asked to do so by you health care professional. This form, along with other tests and x-rays you may have had, will help the long COVID clinic support your assessment and any recommendations for treatment.

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Personal Details

Please provide your details to help us find your record. If you are filling this in on behalf of someone else, please enter their details.

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Long COVID Questionnaire

Please complete this questionnaire only if requested to do so by your GP practice

1. Have you made a full recovery or are you still troubled by symptoms? :

2. Are you more breathless now than you were before your COVID illness? :

3. Do you feel fatigued (worn out/lacking energy or zest) compared with how you were before your COVID illness? : *

4. Do you have a cough (different from any cough you may have had before COVID19)? : *

5. Do you get any palpitations? (sense that you can feel your heart pounding or racing) : *

6. How is your physical strength? Do you feel so weak that it still limiting what you can do (more than you were pre your COVID illness)?: *

E.g. could you work from home, do fewer hours, or do different tasks at work?

7. Do you have any myalgia (‘aching in your muscles’)? :

8. Do you have anosmia (‘no sense of smell’)? : *

9. Have you lost your sense of taste? :

10. Is your sleep disturbed (more than it was pre-COVID)? : *

11. Have you had any nightmares or flashbacks? : *

12. On your mood, is your mood low/do you feel down in the dumps/lacking in motivation/no pleasure in anything? : *

12b. Do you find yourself feeling anxious/worrying more than you used to? : *

13. Have you lost weight (more than ½ stone, 3 Kg) since your COVID illness? : *

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Confirmation

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Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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