COVID-19 Rehabilitation Screening Tool

This questionnaire is to find out if you are continuing to experience diagnosed coronavirus or suspected coronavirus symptoms.

You may be referred to other services to provide additional support and treatment for your symptoms.

COVID-19 Rehabilitation Screening Tool

COVID-19 Rehabilitation Screening Tool

Patient Details

Please use date format DD/MM/YYYY

How have you been affected by Coronavirus?

Below are some questions about how you might have been affected since your illness. If there are other ways that you've been affected, then there will be a chance to describe these at the end of the form.

Breathlessness

On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you: (Please leave blank if you do not perform this activity)

At rest?

Now:
Pre-COVID:

On dressing yourself?

Now:
Pre-COVID:

On walking up a flight of stairs?

Now:
Pre-COVID:

Cardiac (heart related) chest pain (angina)

Do you have any chest discomfort, shortness of breath, cardiac chest pains or symptoms of angina? *
Is this new (following COVID) or old? *
How is it affecting you in activities of daily living on the scale of 0-10 below (0 being no impact, 10 being significant impact): *

Palpitations or feeling of your own heart flutters

Do you have symptoms of heart palpitations/flutters? *
Is this new (following COVID) or old? *
How is it affecting you in activities of daily living on the scale of 0-10 below (0 being no impact, 10 being significant impact): *

Stroke

Have you had a stroke since having COVID like symptoms? *
Has a stroke had an impact on your ability to carry out your normal daily activities? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Throat/breathing problems

Have you developed any changes in the sensitivity of your throat such as troublesome cough or noisy breathing? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Voice

Have you or your family noticed any changes to your voice such as difficulty being heard, changed quality of the voice, your voice tiring by the end of the day or an inability to change the pitch of your voice? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Swallowing

Are you having difficulties eating, drinking or swallowing such as coughing, choking or avoiding any food or drinks? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Nutrition (Eating)

Are you or your family concerned that you have ongoing weight loss or any ongoing nutritional concerns as a result of COVID-19? *
Please rank your appetite or interest in eating on a scale of 0-10 since COVID-19 (0 being same as usual/no problems, 10 being very severe problems/reduction): *

Mobility (Movement)

On a 0-10 scale, how severe are any problems you have in walking about, for example, 0 means you have no problems, 10 means you are completely unable to walk about.

Now: *
Pre-COVID: *

Fatigue or Exhaustion

Do you become fatigued (extremely tired) more easily compared to before your illness? *

How severely does this affect your mobility (movement), personal care, activities or enjoyment of life? (0 being not affecting, 10 being very severely impacting)

Now: *
Pre-COVID: *

Personal Care

On a 0-10 scale, how severe are any problems you have in personal care such as washing and dressing yourself? (0 means you have no problems, 10 means you are completely unable to do your personal care)

Now: *
Pre-COVID: *

Continence (control of bowel or bladder)

Since your illness are you having any new problems with:

Controlling your bowel? *
Controlling your bladder? *

Usual Activities

On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as household chores, leisure activities, work or study?
(0 means you have no problems, 10 means you are completely unable to do your usual activities)

Now: *
Pre-COVID: *

Pain / Discomfort

On a 0-10 scale, how severe is any pain or discomfort you have? (0 means you have no pain or discomfort, 10 means you have extremely severe pain)

Now: *
Pre-COVID: *

Cognition (the ability to think, memory, clarity of thought, how we organise ourselves, how we process things)

Since your illness have you had new or worsened difficulty with:

Concentrating? *
Short term memory? *

Cognitive-Communication (how our ability to think and organise our thoughts impacts on how we are able to communicate with others both verbally and non-verbally)

Have you or your family noticed any change in the way you communicate with people, such as making sense of things people say to you, putting thoughts into words, difficulty reading or having a conversation? *
Rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact): *

Anxiety (feeling worried or nervous)

On a 0-10 scale, how severe is the anxiety you are experiencing? (0 means you are not anxious, 10 means you are extremely anxious)

Now: *
Pre-COVID: *

Depression (sadness or lack of interest)

On a 0-10 scale, how severe is the depression you are experiencing? (0 means you are not depressed, 10 means you have extreme depression)

Now: *
Pre-COVID: *

Global Perceived Health

How good or bad is your health overall? (0 means the worst health you can imagine, 10 means the best health you can imagine)

Now: *
Pre-COVID: *

Vocation (Employment)

Has your illness affected your ability to do your usual work?

Family/Carers Views

Additional Information

Would you be prepared to be contacted for future research?