Long Covid – Post-Covid Screening Questionnaire

The purpose of the questionnaire is to identify patients who may benefit from a comprehensive face to face multi-disciplinary assessment if symptoms persist 10-12 weeks after the acute illness.

Please only submit this form if you have been tested positive for Covid in the past 3 months, still have persisting symptoms and have not seen a GP in the past 3 months. The GP will then review your submission and the practice will respond to any significant results. The practice will not contact you if you do no meet the above criteria but the questionnaire results will be saved to your clinical record.

Long Covid - Post-Covid Screening Questionnaire

Patient Details

1. Have you made a full recovery or are you still troubled by symptoms?
2. Are you more breathless now than you were before your COVID illness?
3. Do you feel fatigued (worn out/lacking energy or zest) compared with how you were before your COVID illness?
4. Do you have a cough (different from any cough you may have had before COVID-19)?
5. Do you get any palpitations? (sense that you can feel your heart pounding or racing)
6. How is your physical strength? Do you feel so weak that it is limiting what you can do (more than you were pre your COVID illness)?
7. Do you have any myalgia (‘aching in your muscles’)?
8. Do you have anosmia (‘no sense of smell’)?
9. Have you lost your sense of taste?
10. Is your sleep disturbed (more than it was pre-COVID)?
11. Have you had any nightmares or flashbacks?
12. On your mood, is your mood low/do you feel down in the dumps/lacking in motivation/no pleasure in anything?
12b. Do you find yourself feeling anxious/worrying more than you used to?
13. Have you lost weight (more than ½ stone, 3 Kg) since your COVID illness?