COVID History
Did you have COVID-19?
Yes
No
Unsure
For how many months do you feel you may have had Post-COVID for?
Were you hospitalized as a result of COVID-19?
Yes
No
How would you rate the severity of your initial COVID infection?
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
Did you recover from your initial COVID infection?
Yes
No, I still have symptoms
Unsure
Did symptoms return or did you develop new persistent symptoms after your initial COVID infection?
Yes, symptoms returned
No, I developed new symptoms
No
Unsure
If you recovered from your initial infection, how long after did you start experiencing Post COVID symptoms?
< 1 Month
1-3 Months
3-6 Months
> 6 Months
NA
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Please rate the overall severity of your Post-COVID symptoms on a scale of 1-10?
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
Which of the following care providers have you seen to manage your Post-COVID symptoms?
General Medicine/Primary care provider
General Surgeon
Cardiologist
Mental Health Specialist (Psychiatrist/Psychologist)
Pulmonologist
Endocrinologist
Neurologist
Infectious Disease Specialist
Allergist/Immunologist
Gastroenterologist/Hepatologist
Hematologist
Rheumatologist
Nephrologist
Urologist
Dermatologist
Ophthalmologist
Ear Nose and Throat Specialist
Dentist
Physical Therapist
Occupational Therapist
Speech Pathologist
Sleep Specialist
Have you been diagnosed with Post-COVID, Long COVID or PASC (Post-Acute Sequelae of COVID-19) by a healthcare provider?
Yes
No
Have you received the COVID-19 vaccine?
Yes
No
Are any of your family members also experiencing Post-COVID symptoms?
Yes
No
Unsure
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Neurological Symptoms
Which of the following neurological symptoms are you experiencing?
Dental Issues (eg broken or cracked teeth)
Migraines
Recurrent headaches
Sinus pain
Brain Fog
Convulsions
Difficulty with speaking or using the wrong word
Impaired Memory
Shaking/Tremor
Tingling/Pins and Needles Feeling
Trouble Concentrating
Seizures
Weakness of Arms
Weakness of Legs
Numbness
Trouble Standing
Trouble Walking
Dysautonomia or "POTS"
Lightheadedness
Dizziness
Vertigo
Confusion
Other
Please rate the overall severity of your head and neurological symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Ear, Nose and Throat Symptoms
Which of the following ear, nose and throat symptoms are you experiencing?
Sore Throat
Sinus Pain/Congestion
Nose Bleeds
Earaches
Hearing Loss
Tinnitus (Ringing in Ears)
Eye Pain
Vision Loss
Mouth Sores
Dental Issues
Difficulty Swallowing
Hoarse Voice
Other
Please rate the overall severity of your ear, nose and throat symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Cardiovascular Symptoms
Which of the following cardiovascular symptoms are you experiencing?
High Blood Pressure
Low Blood Pressure
Palpitations (heart "fluttering" or skipping beats)
Fast Heart Rate
Slow Heart Rate
Irregular Heart Rhythm
Chest Pain or Tightness
Syncopal Episodes/Fainting
Pain / Tightness in the Legs When Walking
New or Worsened Varicose Veins
Change in Color of Fingers/ Toes
Swelling of the Legs/Feet
Shortness of Breath When Laying Down Flat
Elevated Cholesterol
Dizziness on standing (lightheadedness)
Please rate the overall severity of your cardiovascular symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Respiratory Symptoms
Which of the following respiratory symptoms are you experiencing?
Shortness of Breath
Pain in Chest When Taking a Deep Breath
Cough
Coughing up Blood
Wheezing
Stopping Breathing/Gasping for Air when Sleeping
Snoring
Low Oxygen Levels/Saturation at Rest
Low Oxygen Levels/Saturation with Movement
Other
Please rate the overall severity of your respiratory symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Gastrointestinal Symptoms
Which of the following stomach and digestive symptoms are you experiencing?
Abdominal Pain
Change in Stool
Jaundice (yellow discolouration to the whites of eyes or skin)
Bloating
Burning Pain in Stomach
Constipation
Cramping
Diarrhea
New Food Allergies
Gas
Hearburn
Loss of Appitite
Nausea
Stomach Pain
Vomiting
Other
Please rate the overall severity of your gastrointestinal symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Endocrine and Hormonal Symptoms
Which of the following endocrine symptoms are you experiencing?
Changes in Menstrual Period Cycles
Feeling Cold easily
Feeling Hot and Sweaty
High Blood Sugar
Low Blood Sugar
Thinning Hair
Weight Gain
Weight Loss
Infertility
New Diabetes Diagnosis
Other
Please rate the overall severity of your endocrine symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Joint and Muscle Pain Symptoms
Which of the following Joint and Muscle Pain are you experiencing?
Swelling
Stiff or enlarged Joint
Numbness
Painful Movement
Difficulty Bending or Straightening the Joint
Loss of Motion
Red, Hot or Swollen Joint
Other
Please rate the overall severity of your joint and muscular pain symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Mental Health Symptoms
Which of the following mental health symptoms are you experiencig?
Anxiety
Depression
Hallucinations
Mood Swings
Psychosis
Personality Changes
PTSD (Post traumatic stress)
Other
Please rate the overall severity of your mental health symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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General Symptoms
Which of the following other symptoms are you experiencing?
Chills
Cold hands or feet
Excessive Thirst
Fatigue
Fever
Itchy Skin
Loss of Smell
Loss of Taste
Rash
Restless Sleep/Insomnia
Malaise (Feeling Like you Have the Flu)
Other
Please rate the overall severity of your other symptoms on a scale of 1 to 10.
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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General Ability
Have you had to reduce your hours at work or had to have workplace accomodationsince you got sick?
Yes
No
N/A
Are you physically able to manage your household chores and responsibilities independently?
Yes
No
N/A
Overall, what was your quality of life before Post-COVID?
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
How would you rate your current quality of life?
Least Severe
1
2
3
4
5
6
7
8
9
Most Severe
10
1 is Least Severe, 10 is Most Severe
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Community Support Questions
Do you participate in any online COVID support groups or social platforms on your own or through a clinic? SELECT ALL THAT APPLY.
Yes - I am part of a Facebook COVID Support Group.
Yes - I am part of a COVID Support Group on some other social media platform other than Facebook.
Yes - I am part of an online COVID Support Group offered through a clinic.
None of the above
How interested would you be in joining a Private global online COVID support community that allows you to connect with other sufferers, clinicians, experts, and specialists who provide care to those who suffer from Post-COVID?
Very Interested
Somewhat Interested
Not Sure
Not at all Interested
Using a scale of 1 to 5, where 1 means not at all interested and 5 means very interested, how interested are you in the following:
1
2
3
4
5
E-Courses designed to help you improve your health and well-being as it relates to Post-COVID
Vitamins and supplements commonly used to minimize the effects of Post-COVID.
Small group therapy sessions with others who have similar issues, ailments, or challenges.
Private, individual therapy sessions.
Instructional and/or Motivational videos.
Infographics to help you focus on aspects of treatment.
Podcasts with people from the Post-COVID community including clinicians, patients, and
specialists.
Accessing information from a community library for resources such as self-help guides, articles,
etc.
Connect one-on-one with clinicians who specialize in Post-COVID treatment.
Webinars with clinicians
(online)
, experts, or specialists.
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Demographic Questions
Are you employed:
Full Time
Part Time
Retired
Unemployed
On Leave
Other
What industry do you work in:
Health Care
Education
Finance
Manufacturing
Logistics, Retail
Other
What industry do you work in:
Health Care
Education
Finance
Manufacturing
Logistics, Retail
Other
What was/is your title or role:
Managerial
Sales
Working with clients in person
Operations
Administrative
Other
What was the highest level of education that you completed:
Postgraduate
University
College
Highschool
Technical School/Program
Prefer not to say
Other
Which Social Media platforms and websites listed below do you visit regularly
Facebook
Instagram
Twitter
YouTube
LinkedIn
TikTok
Have you ever completed or used an online tutorial to learn a new skill, recipe, or activity?
Yes
No
Have you ever completed an online course for professional or personal improvement?
Yes
No
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Personal Information
First Name
*
Last Name
*
Email
*
example@example.com
Province
Please Select
Ontario
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Quebec
Saskatchewan
Yukon
Age in Years
Gender
Would you like to join our Newsletter list? We can send you invites to free support sessions and other activities.
Yes
No
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