Treatment outcomes survey

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This survey takes around 3 to 9 minutes to complete.

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What is your chronic illness?

If you have more than one, please pick the main illness that started first.

Long COVID / PASC (post acute sequelae of COVID-19)

COVID vaccine injury - serious long-term side effects after vaccination

ME/CFS - Myalgic encephalomyelitis/chronic fatigue syndrome

None of the above

Clear selection

How did you find out about this survey? e.g. r/CovidLongHaulers, @LongHaulWiki

If there is a pre-filled answer below that is correct, please do not change it.

During the worst month of your illness, did you spend more than half of your day (your waking hours) in bed, on a couch, or lying down?

Yes

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In the past 30 days, did you spend more than half of your day (your waking hours) in bed, on a couch, or lying down?

Yes

Not applicable - my last 30 days overlap with my worst month of illness.

Clear selection

During the worst month of your illness, how long could you walk continuously WITHOUT causing your symptoms or health to worsen?

Over an hour

30-60 minutes

15-29 minutes

5-14 minutes

1-4 minutes

Less than 1 minute

Could not walk due to my chronic illness

I don't know how to answer this question. e.g. limb differences, other disability, etc.

Clear selection

In the past 30 days, how long could you walk continuously WITHOUT causing your symptoms or health to worsen?

Over an hour

30-60 minutes

15-29 minutes

5-14 minutes

1-4 minutes

Less than 1 minute

Could not walk due to my chronic illness

I don't know how to answer this question. e.g. limb differences, other disability, etc.

Not applicable - my last 30 days overlap with my worst month of illness.

Clear selection

During the worst month of your illness, were you ABLE to work? Specifically, were you able to work the last job you had from before your chronic illness?

Able to work my last job full-time.

Able to work my last job full-time, but only with accommodations (e.g. working at home/remotely).

Able to work my last job only part-time.

Not able to work my last job at all.

Clear selection

In the past 30 days, were you ABLE to work? Specifically, were you able to work the last job you had from before your chronic illness?

Able to work my last job full-time.

Able to work my last job full-time, but only with accommodations (e.g. working at home/remotely).

Able to work my last job only part-time.

Not able to work my last job at all.

Not applicable - my last 30 days overlap with my worst month of illness.

Clear selection

For the worst month of your illness, please rate your symptoms on a scale from 0-4. 0 = Symptoms do not bother me, 4 = Worst suffering imaginable.

If you do not have a particular symptom, please choose the first option "Did not have these symptoms".

Did not have these symptoms

[0] Symptoms do not bother me

[1]

[2]

[3]

[4] Worst suffering imaginable

Pain, neuropathy, paresthesia

Depression

Brain fog, memory problems, or cognitive difficulties

Trouble falling or staying asleep

Any bleeding disorders

Any blood clotting disorders (too much clotting)

POTS or feeling faint when going from lying down to standing up

Food intolerances / allergies

Other chronic illness symptoms not listed above

Did not have these symptoms

[0] Symptoms do not bother me

[1]

[2]

[3]

[4] Worst suffering imaginable

Pain, neuropathy, paresthesia

Depression

Brain fog, memory problems, or cognitive difficulties

Trouble falling or staying asleep

Any bleeding disorders

Any blood clotting disorders (too much clotting)

POTS or feeling faint when going from lying down to standing up

Food intolerances / allergies

Other chronic illness symptoms not listed above

Clear selection

For the past 30 days, please rate your symptoms on a scale from 0-4. 0 = Symptoms do not bother me, 4 = Worst suffering imaginable.

If your last 30 days overlap with my worst month of illness, please skip this question and answer the next one.

Did not have these symptoms

[0] Symptoms do not bother me

[1]

[2]

[3]

[4] Worst suffering imaginable

Pain, neuropathy, paresthesia

Depression

Brain fog, memory problems, or cognitive difficulties

Trouble falling or staying asleep

Any bleeding disorders

Any blood clotting disorders (too much clotting)

POTS or feeling faint when going from lying down to standing up

Food intolerances / allergies

Other chronic illness symptoms not listed above

Did not have these symptoms

[0] Symptoms do not bother me

[1]

[2]

[3]

[4] Worst suffering imaginable

Pain, neuropathy, paresthesia

Depression

Brain fog, memory problems, or cognitive difficulties

Trouble falling or staying asleep

Any bleeding disorders

Any blood clotting disorders (too much clotting)

POTS or feeling faint when going from lying down to standing up

Food intolerances / allergies

Other chronic illness symptoms not listed above

Clear selection

Biological sex

If there is any question on this survey that you do not wish to answer, please leave it blank.

Female

Male

Other - intersex, XXY chromosomes, XYY chromosomes, etc.

Clear selection

Age in years

Please use numbers instead of words, e.g. 60 instead of sixty.

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