Ā | Questions | Ā | Ā | ||
---|---|---|---|---|---|
1 | Have you previously tested positive for COVID-19? | Yes | No | ||
2 | Have you fully recovered from your COVID-19 illness? | Yes | No | ||
Are you currently experiencing any of the following | |||||
3 | Fatigue or tiredness that persists even after rest or sleep? | Yes | No | ||
4 | Difficulty breathing or shortness of breath? | Yes | No | ||
5 | Pain or pressure in the chest? | Yes | No | ||
6 | Joint or muscle pain? | Yes | No | ||
7 | Headaches? | Yes | No | ||
8 | Difficulty concentrating or mental confusion? | Yes | No | ||
9 | Loss of taste or smell? | Yes | No | ||
10 | Digestive problems such as nausea, vomiting, or diarrhea? | Yes | No | ||
11 | Skin rashes or lesions? | Yes | No | ||
12 | Mood changes such as depression, anxiety, or irritability? | Yes | No | ||
13 | If you answered yes to any of the above symptoms, how long have you been experiencing these symptoms? | <ā1wk | 1ā3 wk | 3ā6 wk | >ā6 wk |
14 | Have these symptoms affected your ability to perform daily activities or work? | Yes | No | ||
15 | Have you sought medical attention for these symptoms? | Yes | No | ||
16 | Have you received any treatment for these symptoms? | Yes | No | ||
17 | Is there anything else you would like to share about your symptoms or experience with COVID-19? | Yes | No |