Post-Illness Health Screening Questionnaire
Please complete this questionnaire to help us assess your health and recovery following your recent illness.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Date your illness started
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been officially diagnosed with an illness recently?
*
Yes
No
Which symptoms are you currently experiencing? (Select all that apply)
*
Fever
Cough
Shortness of breath
Fatigue
Loss of taste or smell
Muscle aches
Headache
Other
Please rate your current overall health compared to before your illness.
*
Much worse
1
2
3
4
5
6
7
8
9
Much better
10
1 is Much worse, 10 is Much better
In the past week, how often have you experienced the following?
*
Rows
Never
Rarely
Sometimes
Often
Always
Shortness of breath
1
2
3
4
5
Fatigue
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Chest pain
16
17
18
19
20
Joint or muscle pain
21
22
23
24
25
Have you resumed your normal daily activities?
*
Yes, fully
Partially
No, not yet
Do you have any ongoing medical conditions that have worsened since your illness?
*
Yes
No
Not applicable
Is there anything else you would like to share about your health or recovery?
Submit Screening
Should be Empty: