Patient questionnaire for Long Covid

Dear Patient,

You have suffered a Covid-19 infection in recent weeks.

Many people who recover from Covid-19 still experience limitations in their performance that they do not necessarily attribute to the Covid-19 infection.

For this reason, please provide answers to the following 14 questions concerning performance limitations after recovering from Covid-19. The questions concern typical performance limitations following Covid-19. Please answer each question with: not at all, a little, noticeably/often or a lot/frequently. A cross is sufficient in each case.

We recommend that you contact your doctor regarding Long Covid if you are concerned about any of the issues raised in the questionnaire. Please take the completed questionnaire with you to your doctor's appointment. Your doctor will then decide on possible further tests and treatment based on the information you provide.

Download symptom checker

Download the Long Covid symptom checker here to take to your doctor.

Download

The following will give you an idea of the questions in the symptom checker:

1) Since Covid-19, I have had problems breathing or a feeling of shortness of breath when exercising

2) Since Covid-19, I have experienced problems climbing stairs and exercising my muscles

3) Since Covid-19, I have experienced persistent coughing

4) Since Covid-19, I have had heart palpitations

5) Since Covid-19, I have felt more tired, lethargic or weak

6) Since Covid-19, I have experienced joint or muscle pain

7) Since Covid-19, I have had problems with my sense of smell or taste 

8) Since Covid-19, I have had problems with balance and fine motor skills  

9) Since Covid-19, I have experienced problems finding words

10) Since COVID-19, I have had problems concentrating or speaking long sentences 

11) Since COVID-19, I have experienced anxiety and sleep disorders

12) Since COVID-19, I have felt listless, disinterested and isolated

13) Since COVID-19, I have had problems controlling my emotions 

14) The awful experience of the Covid-19 infection refuses to let go of me 

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