COVID-19 Recovery Assessment Form
Please complete this form to help us assess your recovery progress and ongoing health status following COVID-19 infection.
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 COVID-19 Diagnosis
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Recovery (when you tested negative or symptoms resolved)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently experiencing any symptoms?
*
Yes
No
Please rate the severity of the following symptoms in the past 7 days:
*
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Shortness of breath
5
6
7
8
Cough
9
10
11
12
Muscle or joint pain
13
14
15
16
Loss of taste or smell
17
18
19
20
Difficulty concentrating
21
22
23
24
Chest pain
25
26
27
28
Headache
29
30
31
32
How would you rate your overall health today?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Are you able to perform your usual daily activities as before your illness?
*
Yes, without difficulty
Yes, but with some limitations
No, I am unable to perform usual activities
Have you experienced any of the following complications since your recovery? (Select all that apply)
Blood clots
Heart issues
Lung problems
Neurological symptoms
Other
Do you feel you need further medical follow-up or support?
Yes
No
If you have any additional comments or concerns, please share them below:
Submit Assessment
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