SF-36 Health Assessment After COVID-19 Infection – The COVID-19 Long Haul Foundation

In General How Would You Characterize Your Health

	Excellent	Very Good	Good	Fair	Poor
Level of Health	Level of Health Excellent	Level of Health Very Good	Level of Health Good	Level of Health Fair	Level of Health Poor

Compared to Your Health Prior to COVID-19 How Would You Rate Your Fitness

How would you rate your level of health as a COVID-19 Survivor?

Limitation of Activities

	Yes, Limited A-lot	Yes, Limited A-little	No, Not Limited At All
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.	Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. Yes, Limited A-lot	Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. Yes, Limited A-little	Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. No, Not Limited At All
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited A-lot	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited A-little	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf No, Not Limited At All
Lifting or carrying groceries	Lifting or carrying groceries Yes, Limited A-lot	Lifting or carrying groceries Yes, Limited A-little	Lifting or carrying groceries No, Not Limited At All
Climbing several flights of stairs	Climbing several flights of stairs Yes, Limited A-lot	Climbing several flights of stairs Yes, Limited A-little	Climbing several flights of stairs No, Not Limited At All
Climbing one flight of stairs	Climbing one flight of stairs Yes, Limited A-lot	Climbing one flight of stairs Yes, Limited A-little	Climbing one flight of stairs No, Not Limited At All
Bending, kneeling, or stooping	Bending, kneeling, or stooping Yes, Limited A-lot	Bending, kneeling, or stooping Yes, Limited A-little	Bending, kneeling, or stooping No, Not Limited At All
Walking more than a mile	Walking more than a mile Yes, Limited A-lot	Walking more than a mile Yes, Limited A-little	Walking more than a mile No, Not Limited At All
Walking several blocks	Walking several blocks Yes, Limited A-lot	Walking several blocks Yes, Limited A-little	Walking several blocks No, Not Limited At All
Walking one block	Walking one block Yes, Limited A-lot	Walking one block Yes, Limited A-little	Walking one block No, Not Limited At All
Bathing or dressing yourself	Bathing or dressing yourself Yes, Limited A-lot	Bathing or dressing yourself Yes, Limited A-little	Bathing or dressing yourself No, Not Limited At All

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Physical Health Problems

Yes
No

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Accomplished less than you would like

Yes
No

Were limited in the kind of work or other activities

Yes
No

Had difficulty performing the work or other activities (for example, it took extra effort)

Yes
No

Emotional Health

Yes
No

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Cut down the amount of time you spent on work or other activities

Yes
No

Accomplished less than you would like

Yes
No

Didn't do work or other activities as carefully as usual

Yes
No

Social Activities

Emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

Pain

How much bodily pain have you had during the past 4 weeks?

How Disabling is Your Pain?

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Breathing Patterns

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Emotional Health Post COVID-19 Long-haul Assessment

Emotion & Energy is Good:

These questions are about how you feel and how things have been with you during the last 4 weeks. For each question, please give the answer that comes closest to the way you have been feeling.

Did you feel full of pep?

Have you been a very nervous person?

Have you felt so down in the dumps that nothing could cheer you up?

Have you felt calm and peaceful?

Have you felt downhearted and blue?

Did you feel worn out?

Do You Notice Abnormal or Sudden Mood Swings

Do You Notice Changes In Your Mental Thought Process?

Do You Experience Brain Fog, Wooziness & or Confusion?

Do You Experience Vision Problems or a Strange Haze-like Visual Disturbance?

Have you been a happy person?

Did you feel tired?

Ability to Socialize as a Long-haul Survivor

I Am Capable of Social Activities

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

I Am Unable to Do Anything Strenuous

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?