Post-COVID Self Assessment - Madonna Rehabilitation Hospitals

Post-COVID Symptoms Assessment

This assessment is for people who had a confirmed or suspected diagnosis of coronavirus disease (COVID-19). It is to help understand if any current symptoms may be due to the lingering impact of COVID-19. The assessment may be taken for oneself or on behalf of another person.

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Post-COVID Symptoms Assessment(Required)

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If you are experiencing a medical emergency, please seek immediate attention(Required)

The results of the assessment do not constitute a medical diagnosis. However, you can discuss the results of this survey with your physician or a medical care provider. Results will be stored in a HIPAA-compliant database.

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Have you ever tested positive or been diagnosed with a COVID-19 infection?(Required)

Yes

Do you believe you have had COVID-19, but did not receive an official diagnosis?(Required)

Yes

How many times do you believe you have been infected with COVID-19(Required)

4 or more

What is the date of your first known or suspected infection?(Required)

Please make an approximate guess for the day.

What is the date of your most recent known or suspected infection?(Required)

Please make an approximate guess for the day.

What is your age range?(Required)

Let's cover your experience with physical symptoms.(Required)

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How frequently do you experience fatigue or tiredness?(Required)

How frequently do you experience shortness of breath or difficulty breathing?(Required)

How frequently do you experience lightheadedness, fainting or rapid heartbeat?(Required)

How frequently do you experience muscle weakness?(Required)

How frequently do you experience balance issues?(Required)

How frequently do you experience reduced activity tolerance or worsening symptoms with exercise?(Required)

How frequently do you experience pain in your chest, head, muscles joints or other areas of the body?(Required)

How do these symptoms compare to before your possible COVID-19 infection?(Required)

Better

Worse

Same

Let's cover your experience with functional symptoms.(Required)

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How frequently do you experience voice or swallowing challenges?(Required)

How frequently do you experience trouble completing daily activities, such as shopping, cleaning, driving or meal preparation?(Required)

How frequently do you experience trouble completing self-care tasks, such as walking, feeding, bathing, dressing or grooming?(Required)

How frequently do you experience difficulty in the work or school environment?(Required)

How do these symptoms compare to before your possible COVID-19 infection?(Required)

Better

Worse

Same

Let's cover your experience with mental symptoms.(Required)

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How frequently do you experience memory difficulties?(Required)

How frequently do you experience decreased concentration or attention?(Required)

How frequently do you experience brain fog?(Required)

How frequently do you experience slowed mental processing?(Required)

How do these symptoms compare to before your possible COVID-19 infection?(Required)

Better

Worse

Same

Let's cover your experience with emotional symptoms(Required)

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How frequently do you experience anxiety?(Required)

How frequently do you experience depression?(Required)

How frequently do you experience changes in sleep?(Required)

How do these symptoms compare to before your possible COVID-19 infection?(Required)

Better

Worse

Same

Thinking about your life before your suspected or confirmed COVID-19 infection, where were you?(Required)

Choose the number that best describes your prior quality of life, before your suspected or confirmed COVID-19.

Taking everything in your life into account, please rate your current overall quality of life.(Required)

Was there a time in the past 12 months when you needed to see a doctor but could not afford it?(Required)

Yes

Don’t know/Not sure

What is the primary source of your health care coverage?(Required)

A plan purchased through an employer or union

A plan that you or another family member buys on your own

Medicare

Medicaid or other state program

TRICARE (formerly CHAMPUS), VA, or Military

Alaska Native, Indian Health Service, Tribal Health Services

None

Don’t know/Not sure

Other

Would you be interested in participating in future post-COVID research studies?(Required)

Post-COVID is an emerging field of study. Madonna’s Institute for Rehabilitation Science and Engineering leads research to enhance knowledge about the disease and develop best practices for rehabilitation care.

Yes

Upon submitting this form, your results will be sent to the provided email address below. Additional contact information is not required. All answers are confidential.

First Name

Last Name

Phone

Email(Required)