JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Long Covid Analysis Survey
A short form to be filled out at your own discretion that will be used to analyze the potential causes and/or risk factors associated with long covid
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Are you still currently suffering with long covid?
*
Yes
No
How long has your long covid lasted
*
Under 2 months
2 - 6 months
6 months - 1 year
1 year+
Has there been times when your long covid symptoms have worsened?
*
Yes
No
Could you specify your symptoms relating to your long covid?
*
Fatigue
Brain fog/ loss of concentration
Cough
Joint Pain
Anxiety/ palpatations
Fatigue/ trouble sleeping
Shortness of breath
Dizziness
Other:
Required
Do you have a history of mental health issues?
*
Yes
No
If so could you specify what?
Your answer
Around time of long covid onset was there any change within your life?
*
Yes
No
If so, could you specify what?
Your answer
Has your long covid showed any signs of improvement?
*
Yes
No
If so when and where there any specific circumstances that caused the onset of this improvement?
Your answer
Do you think your long covid could be related to your emotional health?
*
Yes
No
Depending on your answer to the above, why
*
Your answer
Have you noticed anything that make your symptoms worsen?
*
Yes
No
If so, what?
Your answer
Is there anything else you feel of importance that this hasn't covered relating to your long COVID?
Your answer
If you would feel comfortable with me contacting you to discuss your answers to this survey, please submit your preferred contact details below
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
