Long COVID Patient Feedback Survey
Please share your experience with long COVID to help us improve patient care and support.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
How long have you been experiencing long COVID symptoms?
*
Please Select
Less than 1 month
1-3 months
3-6 months
6-12 months
Over 1 year
Please indicate which symptoms you are currently experiencing (select all that apply):
*
Fatigue
Shortness of breath
Brain fog or difficulty concentrating
Chest pain
Joint or muscle pain
Loss of taste or smell
Anxiety or depression
Sleep disturbances
Other
How would you rate the severity of your symptoms over the past week?
*
No symptoms
1
2
3
4
5
6
7
8
9
Very severe
10
1 is No symptoms, 10 is Very severe
How much have your long COVID symptoms impacted your daily life?
*
Not at all
A little
Moderately
Severely
Extremely
Please rate your satisfaction with the healthcare support you have received for long COVID:
*
1
2
3
4
5
Have you accessed any of the following services for long COVID? (Select all that apply)
*
Primary care physician
Specialist (e.g., pulmonologist, cardiologist)
Physical therapy
Mental health support
Support group
None
Other
Please provide any additional comments or suggestions regarding your experience with long COVID.
Submit Feedback
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