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Covid-19 Symptom Questionnaire **Confirmed Diagnosis Only**
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Weight
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How long have you been experiencing symptoms?
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Hospital Visit?
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Age Range
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Cough
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If able to get up any phlegm, has it been
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Sore throat
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loss of smell/ alteration of smells
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loss of taste/ alteration of taste
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headache
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Fever
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extreme/ chronic fatigue
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shortness of breath
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Heart Palpitations
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I feel/ felt like
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If I take a deep breathe, I cough
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I have experienced pink eye/ red eyes
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I have developed a stye on my eye
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facial rash or swelling
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tinnitus (ringing in the ears)
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Rash/ hives/ bumps
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Loss of consciousness
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inability to move
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Lack of concentration
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memory issues
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nausea
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vomiting
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Dizziness
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Diarrhea
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Feeling of gurgling when breathing
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mental health effects
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Irritability
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Acid Reflux/ burning feeling in chest or throat
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Feel pulse pounding throughout chest/ head/ arms
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vision changes/ blurry/ worsened
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experienced numbness/ tingling
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Nose
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kidney pain/ stones/ failure
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chest pain
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Joint Pain
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I experience or developed a heart arrythmia (a-fib, a-flutter, tachycardia, bradycardia, heart block).
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costochondritis
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blood pressure- developed
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experienced muscle spasms
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jaw pressure
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hyperhydrosis (excessive sweating)
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dehydration
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dry mouth/ excessive thirst
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Shaking/ twitching
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Stomach Pain
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covid toes/ red fingers or toes
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loss of speech
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brain fog/ delirium
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bronchitis
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rib pain from coughing
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new onset of diabetes or high a1c level
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pneumonia
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pulmonary embolism
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pleural effusions
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pericarditis
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wheezing
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flashes in peripheral vision
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poor sleep pattern/ lack of sleep/ sleep interruption
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Swollen legs
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clots
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back pain
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low oxygen saturation (spo2)
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bloated/ inflammed stomach
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eye pain/ eye pressure
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unsteady/ lack of balance/ poor muscle control
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pricking/ pin poke feelings
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feelings of a lump in your throat
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other gi issues
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sore bleeding gums
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hair loss
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exacerbation of a pre existing condition
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malaise
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check all you have had done or are scheduled to do
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If you have been sent for a test not listed above, please write it below.
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please check all doctors you have been sent to/ consulted with
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If not listed above, please provide the type of doctor you have been to or are scheduled to see
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After seeing a doctor due to covide 19, have you been diagnosed with any of the following?
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Have you been diagnosed with something not listed above that is a direct result of covid?
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Have you been using/ placed on any medications from your doctors that you feel are or have helped you?
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do you feel your doctors have listened to you/ believe you?
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did anyone you were around catch the virus from you?
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After testing positive for covid, did you take an antibodies test?
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Did you have a negative covid test, but test positive for the antibodies?
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Did you experience menstrual changes?
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