Name
*
First Name
Last Name
Contact Number
*
Email
Occupation
Past Medical History
*
Current Medications
*
Allergies
*
Source of Infection
*
Date of Infection
*
Date of Positive Swab
*
Duration of Infection
*
Symptoms
*
Hospital Admission?
*
Yes
No
Current Symptoms
*
Select relevant symptoms
If you selected others please explain
Modified MRC Breathlessness Score
*
0 - “I only get breathless with strenuous exercise”
1 - “I get short of breath when hurrying on the level or walking up a slight hill”
2 - “I walk slower than people of the same age on the level because of breathlessness or
have to stop for breath when walking at my own pace on the level”
3 - “I stop for breath after walking about 100 yards or after a few minutes on the level”
4 - “I am too breathless to leave the house” or “I am breathless when dressing”
1. In general, would you say your health is:
*
1 - Excellent
2 - Very good
3 - Good
4 - Fair
5 - Poor
2. Compared to one year ago, how would you rate your health in general now?
*
1 - Much better now than one year ago
2 - Somewhat better now than one year ago
3 - About the same
4 - Somewhat worse now than one year ago
5 - Much worse now than one year ago
3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
5. Lifting or carrying groceries
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
6. Climbing several flights of stairs
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
7. Climbing one flight of stairs
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
8. Bending, kneeling, or stooping
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
9. Walking more than 1 km
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
10. Walking 500 m
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
11. Walking 100 m
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
12. Bathing or dressing yourself
*
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all
13. Cut down the amount of time you spent on work or other activities
*
1 - Yes
2 - No
14. Accomplished less than you would like
*
1 - Yes
2 - No
15. Were limited in the kind of work or other activities
*
1 - Yes
2 - No
16. Had difficulty performing the work or other activities (for example, it took extra effort)
*
1 - Yes
2 - No
17. Cut down the amount of time you spent on work or other activities
*
1 - Yes
2 - No
18. Accomplished less than you would like
*
1 - Yes
2 - No
19. Didn't do work or other activities as carefully as usual
*
1 - Yes
2 - No
20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours, or groups?
*
1 - Not at all
2 - Slightly
3 - Moderately
4 - Quite a bit
5 - Extremely
21. How much bodily pain have you had during the past 4 weeks?
*
1 - None
2 - Very mild
3 - Mild
4 - Moderate
5 - Severe
6 - Very severe
22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
*
1 - Not at all
2 - A little bit
3 - Moderately
4 - Quite a bit
5 - Extremely
23. Did you feel full of pep?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
24. Have you been a very nervous person?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
25. Have you felt so down in the dumps that nothing could cheer you up?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
26. Have you felt calm and peaceful?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
27. Did you have a lot of energy?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
28. Have you felt downhearted and blue?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
29. Did you feel worn out?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
30. Have you been a happy person?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
31. Did you feel tired?
*
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time
32. 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.)?
*
1 - All of the time
2 - Most of the time
3 - Some of the time
4 - A little of the time
5 - None of the time
33. I seem to get sick a little easier than other people
*
1 - Definitely true
2 - Mostly true
3 - Don’t know
4 - Mostly false
5 - Definitely false
34. I am as healthy as anybody I know
*
1 - Definitely true
2 - Mostly true
3 - Don’t know
4 - Mostly false
5 - Definitely false
35. I expect my health to get worse
*
1 - Definitely true
2 - Mostly true
3 - Don’t know
4 - Mostly false
5 - Definitely false
36. My health is excellent
*
1 - Definitely true
2 - Mostly true
3 - Don’t know
4 - Mostly false
5 - Definitely false
(A) I feel tense or 'wound up'
*
(D) I still enjoy the things I used to enjoy:
*
(A) I get a sort of frightened feeling as if something awful is about to happen:
*
(D) I can laugh and see the funny side of things:
*
(A) Worrying thoughts go through my mind:
*
(D) I feel cheerful:
*
(A) I can sit at ease and feel relaxed:
*
(D) I feel as if I am slowed down:
*
(A) I get a sort of frightened feeling like 'butterflies' in the stomach
*
(D) I have lost interest in my appearance:
*
(A) I feel restless as I have to be on the move:
*
(D) I look forward with enjoyment to things:
*
(A) I get sudden feelings of panic:
*
(D) I can enjoy a good book or radio or TV program:
*
Do you have problems with tiredness ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you need to rest more ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you feel sleepy or drowsy ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you have problems starting things ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you lack energy ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you have less strength in your muscles ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you feel weak ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you have difficulties concentrating ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you make slips of the tongue when speaking ?
*
Less than usual
No more than usual
More than usual
Much more than usual
Do you find it more difficult to find the right word ?
*
Less than usual
No more than usual
More than usual
Much more than usual
How is your memory ?
*
Better than usual
No worse than usual
Worse than usual
Much worse than usual
