Post COVID-19 Patient Self Questionnaire

You have received this questionnaire because you have an upcoming appointment with your GP to talk about your ongoing symptoms of COVID-19. Before the appointment, please complete this symptom questionnaire. It will help your GP plan your care more effectively and track your progress.

If you have difficulty with any of the questions, please leave them blank and the clinician will review them with you during your consultation. Thank you.

Post COVID-19 Patient Self Questionnaire

Post COVID-19 Patient Self Questionnaire

Please specify your sex: *

COVID-19 Overview

Where did you receive care for COVID-19?
What were your COVID-19 test results?

Your COVID-19 symptoms

What symptoms did you have in the first two weeks of COVID-19 infection?
What symptoms have you experienced in the last two weeks?

Your Overall Wellbeing

Do you still feel unwell? *
Are you well enough to work?
Do you feel your symptoms are improving?

Over the last 2 weeks, how often have you been bothered by any of the following problem?

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge: *
Not being able to stop or control worrying: *
Worrying too much about different things: *
Trouble relaxing: *
Being so restless that it's hard to sit still: *
Becoming easily annoyed or irritable: *
Feeling afraid as if something awful might happen: *

Fatigue

The following statements refer to how you usually feel. Per statement you can choose out of one of five answer categories, varying from Never to Always. Please give an answer to each question, even if you have no complaints at the moment.

I am bothered by fatigue: *
I get tired very quickly: *
I don’t do much during the day: *
I have enough energy for everyday life: *
Physically I feel exhausted: *
I have problems to start things: *
I have problems to think clearly: *
I feel no desire to do anything: *
Mentally, I feel exhausted: *
When I am doing something, I can concentrate quite well: *

Breathlessness

Please rate your experience of breathlessness using the scales below. The first is before you had COVID-19,
the second is how you feel now:

Which of the following best describes your experience of breathlessness before you had COVID-19? *
Which of the following best describes your experience of breathlessness after you had COVID-19? *

Your quality of life

Please answer the following questions about how you feel today.

Mobility: *
Self-care: *
Usual activities: *
Pain / Discomfort: *
Anxiety / depression: *

Being Active

Please answer these questions about how you feel after being active.

Do you feel worse after being active? *
How long do you feel worse after activity?

What matters to you?

*