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Covid Survey Form
Post Covid Sequelae & Rehabilitation
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Name
*
Your answer
Age
*
Your answer
Sex
*
Male
Female
Transgender
Prefer not to say
Have you been exposed to corona virus disease (Covid-19)?
*
Yes
No
What are the symptoms you experiencing?
Weakness
Drowsiness
Difficulty breathing or Short of Breath (during activities)
Lack of Interest
Low Blood Pressure
Tiredness or fatigue
Chest pain
Dyspepsia (Indigestion)
Polyphagia( extreme hunger)
Fast-beating (palpitation)
Dizziness on standing
Joint or muscle pain
Cough
Fever
Headache
Difficulty thinking or concentrating “brain fog”
Loss of smell or taste
Depression or anxiety
Please write any other symptoms or disease or complication if you have .
Your answer
Email (optional)
Your answer
Address (just city name)
Your answer
Phone number(optional)
Your answer
Comments
Your answer
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