COVID-19 Long-haul Illness History Please Fill in as much information about your COVID-19 Illness as you remember. Please enable JavaScript in your browser to complete this form. - Step 1 of 2Person Reporting COVID-19 History *FirstLastPerson With COVID-19 Illness *FirstLastDate / Time of Disease On-set (as close to the date as you remember.)DateTimeFirst Symptoms as COVID-19 On-set TemperatureCoughFoul TasteFoul SmellSores iin MouthCracks in CuticlesTrouble BreathingHeadacheConfusionEye SightBruisingOtherIf Other, Please Describe Other COVID-19 Symptoms that You ExperiencedHow Would You Characterize Your COVID-19 IllnessMildModerateDifficultSevereHospitalizedHospitalized-VentilatedWere You Treated by a Physician for your COVID-19 IllnessYesNoWere You Prescribed Medication to Treat your COVID-19 IllnessYesNoMedicationsAntibioticsSteroidsDecongestantsOxygenBlood ThinnersPlateletsVaccineDo You Know How You Were Exposed or From Whom You Contracted COVID-19YesNoDid You Fully Recover From Your Initial IllnessYesNoAfter Your Recovery From COVID-19 What Was the Approximate Date of Onset for Your Long-haul DiseaseMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Information About Your Long-haul Illness HistoryWhat Are ALL of the Problems That You Experience as a COVID-19 Long-haul Survivor? Select All That Apply!FatigueBody AchesShortness of BreathDifficulty Thinking-FocusingAnxietyMemory ProblemsEye-Vision ProblemsDizzinessChest PainCoughJoint PainHeart PalpitationsDiarrheaSore ThroatNight SweatsLoss of SmellLoss of TasteBody AcheFeverChillHair LossDepressionPain in JointsPain in hands & FingersPain in Leg(s)Pain in FeetHeadacheRefluxHeartburnBelchingAbnormal PulseHemorrhageSleep AbnormalitiesDisturbing DreamsFloatersChanging SymptomsLow Back PainAbdominal PainExhaustionNausea-VomitingWeight GainWeight LossDysautonomiaPostural TachycardiaTinnitus-Ringing EarsDry EyesCalf CrampsTremors-ShakingTemperature AbnormalitySkin RashIncreased Need for SleepPain Upper BackThirstNerve SensationsSharp or Sudden Chest PainConfusionIrritabilitySpeech AbnormalitiesMuscle spasmsAdverse Vaccine ReactionBruisingBlood ClotsStrokeHeart AttackLiver ProblemsKidney ProblemsUrinary Tract ProblemsLoss of Libedo-change in sex lifeInjury do to FallSwelling in Feet/AnklesSkin ChangesOtherHow Would You Describe Your COVID-19 Long-haul Conditions?UnchangedSlowly Progressing-getting WorseRapidly ProgressingSlowly Diminishing-getting betterRapid ImprovementComes & GoesAre You Currently Under Physician Care for Your COVID-19 Long-haul IllnessYesNoWhat is Your Physician Doing to Treat Your Long-haul ConditionsWatchful WaitingAntibioticsSteroidsNon-steroidal Anti-inflammatoriesDecongestants Blood ThinnersOxygenAntidepressantsSleep MedicationsPain MedicationsCardiac & BP MedicationsDigestive MedicationsDiabetes MedicationsThyroid MedicationsDiureticsCompression StockingsDietExerciseBed RestDo You Believe That Your Doctor Understands Your ConditionYesNoShows ConcernExpressed DoubtPersonal InformationDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexMaleFemaleHeight (feet & inches)Weight (approximate in pounds)Marital StatusSingleMarriedSeparatedDivorcedCohabitingEmployment StatusEmployedUnemployedRetiredStudentAre You Able to Work?YesNoLimited AbilityDisabledOccupation:NextIllness HistoryPlease Check ALL illnesses that You Have ExperiencedDiabetesCoronary Artery DiseaseHigh CholesterolHypertensionStrokeGoutTuberculosisObesityAnemiaMigraineAllergiesBleeding DisorderDepressionAsthmaCancerHay FeverGoiterEpilepsySleep DisorderKidney DiseaseArthritisInflammatory Bowl DiseaseThyroid DiseasePhlebitis LupusPneumoniaAutoimmune DiseaseStrep InfectionsStaph InfectionsHerpes ZosterHIVUlcersLiver ProblemsHave You Experienced Any of These Problems PRIOR to COVID-19Vision ProblemsDifficulty HearingLoss of SmellMouth & Gum DiseaseDifficulty SwollowingHeart AttackNeurological DisorderInjury Due to FallDisabilityBlood Pressure: DiastolicBlood Pressure: SystolicTemperaturePulse: Beats Per MinuteDaily Diary Baselines: On a Scale of 1 to 10 (10 being Great) How Well Do You Sleep? Selected Value: 0 Check ALL that Apply to Your SleepNightmares-Terrors'Strange DreamsTrouble breathingInsomnia-Can't SleepTinnitus: Ringing in EarsSweatingCramps-Charley HorseRestless Leg(s)Wake throughout NightHeartburn-RefluxNauseaOrgan PainChest PainUrinary ProblemsLoss of Libedo (Sexual Interest) Upon Awakening: How Well Do You Feel on an average morning (10 Feeling Great)? Selected Value: 0 Check ALL that Apply to How You Feel on an average morning after awakeningExhaustedWell RestedConfusedWoozy-DizzyDisorientedHeadacheChest PainAbdominal PainJoint PainHeartburn-RefluxNauseaLow Oxygen LevelSore ThroatSour or Foul TasteBad SmellsAt Noon: Rate Level of ConfusionRate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5At Noon: Rate Level of EnergyRate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5At Noon: Rate Level of Dizziness-InstabilityRate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5At Noon: Rate Level of PainRate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5At Noon: Rate Level of DisabilityRate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Submit