Long-Covid Care Assessment
Please complete this assessment to help us understand your symptoms, experiences, and care needs related to Long-Covid.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did you first experience symptoms of Covid-19?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been officially diagnosed with Long-Covid by a healthcare provider?
*
Yes
No
Not sure
Please indicate which of the following symptoms you are currently experiencing and their severity:
*
Rows
Not at all
Mild
Moderate
Severe
Fatigue
1
2
3
4
Shortness of breath
5
6
7
8
Brain fog (difficulty concentrating)
9
10
11
12
Joint or muscle pain
13
14
15
16
Chest pain or tightness
17
18
19
20
Sleep problems
21
22
23
24
Loss of taste or smell
25
26
27
28
Headache
29
30
31
32
Heart palpitations
33
34
35
36
Anxiety or depression
37
38
39
40
How often do these symptoms affect your daily activities?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How would you rate your overall quality of life since experiencing Long-Covid symptoms?
*
1
2
3
4
5
Do you have any pre-existing medical conditions? (Select all that apply)
Diabetes
Heart disease
Asthma or respiratory conditions
Autoimmune disorder
None
Other
What kind of support or care do you currently need? (Select all that apply)
Medical treatment
Physical therapy
Mental health support
Assistance with daily activities
Information and education about Long-Covid
Other
Please provide any additional information about your experience with Long-Covid or specific care needs.
Signature
*
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