Long COVID Patient Intake Questionnaire
Please complete this questionnaire to help us understand your symptoms and health status related to long COVID. Your responses will assist your healthcare provider in delivering appropriate care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously been diagnosed with COVID-19?
*
Yes
No
Not Sure
When did you first experience COVID-19 symptoms?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate which of the following symptoms you are currently experiencing (select all that apply):
*
Fatigue
Shortness of breath
Brain fog or difficulty concentrating
Chest pain
Joint or muscle pain
Cough
Headache
Sleep disturbances
Loss of taste or smell
Other
Please rate the severity of your most bothersome symptom:
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do you have any pre-existing medical conditions?
Hypertension
Diabetes
Heart disease
Asthma or lung disease
None
Other
Are you currently taking any medications? If yes, please list them.
How much have your symptoms impacted your daily activities?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Please use the table below to indicate how frequently you experience the following symptoms:
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
1
2
3
4
5
Shortness of breath
6
7
8
9
10
Brain fog
11
12
13
14
15
Chest pain
16
17
18
19
20
Joint pain
21
22
23
24
25
Is there anything else you would like your healthcare provider to know? (Optional)
Submit
Should be Empty: