Covid Recovery Rehabilitation Assessment Form
Please complete this assessment to help us understand your post-Covid recovery and rehabilitation needs.
Age Group
*
Please Select
Under 18
18-29
30-44
45-59
60 and above
How would you describe your current overall health compared to before your Covid infection?
*
Much better
About the same
Slightly worse
Much worse
Please rate your current level of fatigue.
*
1
2
3
4
5
How often have you experienced the following symptoms in the past two weeks?
*
Rows
Never
Rarely
Sometimes
Often
Always
Shortness of breath
1
2
3
4
5
Muscle or joint pain
6
7
8
9
10
Difficulty concentrating
11
12
13
14
15
Sleep disturbances
16
17
18
19
20
Anxiety or low mood
21
22
23
24
25
How would you rate your ability to perform daily activities (e.g., dressing, bathing, cooking)?
*
Very difficult
1
2
3
4
No difficulty
5
1 is Very difficult, 5 is No difficulty
Since your Covid recovery, how has your physical activity level changed?
*
Increased
No change
Decreased
Please indicate how much support you feel you need in the following areas.
*
Rows
No support
A little support
Moderate support
A lot of support
Physical rehabilitation
26
27
28
29
Mental health support
30
31
32
33
Nutritional advice
34
35
36
37
Social support
38
39
40
41
Do you currently use any assistive devices for mobility?
*
No
Yes, occasionally
Yes, regularly
Please describe any other ongoing challenges or concerns related to your Covid recovery.
How confident do you feel about managing your recovery and rehabilitation at this time?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
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