JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Screening of postcovid symptoms
Please, fill out the form and you will receive information and advice on the treatment of post-covid syndrome and its prevention. Doctors working with the Association 'Convalescent plasma for treatment of COVID-19' will contact you for further questions and consultation.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Your Doctor's email and telephone number
Your answer
I agree to my personal data being processed for the purposes of the association.
*
yes
no
Required
Your name
*
Your answer
Your country of residence
*
Your answer
Age
*
Your answer
Weight and co-morbidities (other diseases)
*
Your answer
What kind of profession do you practice?
*
Mainly with physical activity
Mainly emotionally loaded
both
Not working
other
Required
When did you get sick with COVID-19 and how many times? If possible, give exact dates and how the disease developed?
*
Your answer
Have you been vaccinated?
*
1 time
2 times
3 times
not vaccinated
other
Required
When have you been vaccinated?
*
2020
2021
2022
2023
not vaccinated
Required
Type of vaccine? (Moderna, Pfizer etc.)
*
Your answer
System complains
*
1. Chills/flushing/sweats
2. Coldness
3. Elevated temperature 37,1-38 C
4. Fatigue
5. Fever
6. Heat intolerance
7. Low temperature
8. Night sweats
9. Other temperature problems
10. Post-Exertional Malaise
11. Skin sensations: burning, tingling, or itchiness without rash
12. Temperature lability
13. Weakness
14. Cold legs or arms
15. Sudden weakness while walking
16. Sudden paralysis/absence of sensation in the face or elsewherefacial paralysis
17. Sudden inability to speak and understand
18. Other
19. None of the kind
Required
Neuropsychiatric-Sensorimotor Symptoms
*
1. Acute (sudden) confusion/disorientation
2. Agnosia (failure to recognize or identify objects despite intact sensory functioning)
3. Cognitive Dysfunction, overall (Brain fog
4. Difficulty problem-solving or decision-making
5. Difficulty thinking
6. Difficulty with executive functioning (planning, organizing, figuring out the sequence of actions, abstracting)
7. Other Cognitive Functioning Symptoms
8. Poor attention or concentration
9. Slowed thoughts
10. Thoughts moving too quickly
11. Other
12. Nothing of that
Required
Neuropsychiatric-Memory Symptom
*
1. Forgetting how to do routine tasks (tying your shoe laces, washing your hands)
2. Long-term memory loss (long-term memory can be anything from remembering yesterday, forgetting you’ve done a task, forgetting recently learned information, or forgetting your third-grade experience)
3. Inability to make new memories
4. Other Memory Symptoms
5. Short-term memory loss (for example, forgetting you’re in the middle of a task)
6. Other
7. Nothing of that kind
Required
Headaches and hallucinations
*
1. Headaches, at the base of the skull
2. Headaches, behind the eyes
3. Headaches, diffuse (entire brain)
4. Headaches, in the temples
5. Headaches, other
6. Headaches/pain after mental exertion
7. Migraines
8. Auditory (hearing) Hallucinations
9. Hallucinations, other
10. Tactile (touch) Hallucinations
11. Visual (seeing) Hallucinations
12. Other
13. Nothing of that kind
Other:
Required
Sensorimotor Symptoms
*
1. Dizziness / vertigo / unsteadiness or balance issues
2. Electrical zaps/electrical shock sensation
3. Inability to cry
4. Inability to yawn
5. Neuralgia (nerve pain)
6. Numbness/loss of sensation
7. Numbness/weakness on one side of the body only
8. Seizures (confirmed)
9. Seizures (suspected)
10. Sensation of brain pressure
11. Sensation of brain warmth/"on fire"
12. Sensitivity to noise
13. Tingling/prickling/pins and needles sensation
14. Swallowing and breathing disorders
15. Other
16. Nothing of the kind
Required
Emotion and Mood Symptom
*
1. Aggression
2. Anger
3. Anxiety
4. Apathy (lack of feeling, emotion, interest, or concern)
5. Delusions
6. Depression
7. Euphoria (a feeling or state of intense excitement and happiness)
8.Feeling like the world isn’t real (derealization) or Feeling like you aren’t real/like you’re observing yourself from outside your body (depersonalization)
9.Hypomania (a milder form of mania)
10, Impulsivity and Disinhibition
11. Irritability
12. Mania (abnormally elevated/excited mood, decreased need for sleep, occasionally with delusions)
13. Mood Lability
14. Other Emotional Changes Symptoms
15. Sense of doom
16. Suicidality
17. Tearfulness
18. Other
19. Nothing of the kind
Required
Sleep Symptoms
*
Awakened by feeling like you couldn’t breathe
Difficulty falling asleep
Insomnia - sleeping disorders
Lucid dreams (dreams where you are aware you are dreaming or have some control over what you dream about)
Nightmares
Other Sleeping Issues Symptoms
Restless leg syndrome
Sleep apnea
Vivid dreams
Waking up early in the morning
Waking up several times during the night
Other
Nothing of the kind
Required
Speech and Language Symptom
*
Changes to non-primary (second/third) language skills
Difficulting speaking in complete sentences
Difficulty communicating in writing
Difficulty communicating verbally
Difficulty finding the right words while speaking/writing
Difficulty processing/understanding what others say
Difficulty reading/processing written text
Other Speech/Language Symptoms
Slurring words/speech
Speaking unrecognizable words
Other
Nothing of the kind
Required
Taste and Smell Symptom
*
Altered sense of smell
Altered sense of taste
Heightened sense of smell
Heightened sense of taste
Loss of smell
Loss of taste
Phantom smells (imagining/hallucinating smells - smelling things that aren't there)
Phantom taste (imagining/hallucinating tastes - tasting things when there's nothing in your mouth)
Other
Nothing of the kind
Required
Cardiovascular Symptom
*
Abnormally high blood pressure
Abnormally low blood pressure
Blood clots (Thrombosis)
Bradycardia (low heart rate, <60 beats per minute)
Fainting
Heart palpitations
Pain/burning in chest
Tachycardia
Other
Nothing of the kind
Required
Pulmonary Symptoms
*
Cough with mucus production
Dry cough
Episodes of breathing difficulty/gasping for air when your oxygen saturation is normal
Low oxygen levels (<94%)*
Coughing up Blood
Other Respiratory and Sinus Symptoms
Rattling of breath
Shortness of Breath
Other
Nothing of the kind
Required
Musculoskeletal Symptom
*
Joint pain
Muscle aches
Bone ache or burning
Muscle spasms
Stiff neck
Tightness of Chest
Other
Nothing of the kind
Required
HEENT (Head, Ear, Eyes, Nose, Throat) Symptom
*
Bloodshot eyes
Changes in the voice
Changes to the ear canal (such as pressure, blockage, burning, swelling)
Dry eyes
Ear and Hearing Symptoms - Hearing loss
Ear and Hearing Symptoms - Other ear/hearing issues
Ear pain
Eye pressure or pain
Facial paralysis (please indicate where on face was paralyzed)
Floaters
Itchy eyes
Lump in throat/difficulty swallowing
Numbness/loss of sensation in/near the ear
Other eye issues
Pink eye (conjunctivitis)
Redness on the outside of eyes
Runny nose
Seeing things in your peripheral vision
Sensation of facial pressure/numbness, left side
Sensation of facial pressure/numbness, other:
Sensation of facial pressure/numbness, right side
Sensitivity to light
Sneezing
Sore Throat
Blurred vision
Double vision
Total loss of vision
Tunnel vision
Vision symptoms, overall
Other
Nothing of the kind
Required
Gastrointestinal Symptoms
*
Abdominal pain
Constipation
Diarrhea
Feeling full quickly when eating
Hyperactive bowel sensations
Loss of Appetite
Lower Esophagus Burning / gastroesophageal reflux / acid reflux
Nausea
Vomiting
Other
Nothing of the kind
Required
Dermatologic Symptoms
*
Brittle/discolored nail
Itchy skin
Itchy, other
COVID toes (discoloration, swelling, painful, or blistering toes)
Other Skin and Allergy symptoms
Peeling skin
Petechiae (tiny purple, red, or brown spots on the skin, usually on arms, legs, stomach, buttocks, and occasionally inside mouth or on eyelids)
Skin rashes
Visibly inflamed/bulging veins
Other
Nothing of the kind
Required
I
m
munologic/Autoimmune Symptoms
*
Changes in sensitivity to medication
Dermatographia (writing on your skin causes red lines where you scratched)
Heightened reaction to old allergies
New allergies (food, chemical, environmental, etc)
New/unexpected anaphylaxis reaction
Shingles
Other
Nothing of the kind
Required
Reproductive/Genitourinary/Endocrine Symptoms
*
Abnormally heavy periods/clotting
Abnormally irregular periods
All menstrual/period issues - with menstrual cycles
All menstrual/period issues - post-menopausal and no/other menstrual cycles
All Reproductive
Decrease in size of testicles/penis cis_men
Decrease in size of testicles/penis nonbinary
Early Menopause cis_women_in_40s
Early Menopause cis_women_under_40
Extreme thirst
High blood sugar (if measured)
Low blood sugar (if measured)
Other menstrual issues
Other semen/penis/testicles issues cis_men
Other semen/penis/testicles issues nonbinary
Pain in testicles cis_men
Pain in testicles nonbinary
Post-Menopausal bleeding/spotting cis_women_in_40s
Post-Menopausal bleeding/spotting cis_women_over_49
Reproductive and Urinary Symptoms - Bladder control issues
Urinary issues, other
Post-Menopausal bleeding/spotting nonbinary
Other
Nothing of the kind
Required
How would you assess the severity of your disease in the past?
*
I could not leave my house
I could not work and perform my daily duties for days
I could work but sometimes I felt very bad for the whole day
I workеd and performеd my daily duties normally
Other:
Required
How would you assess the severity of your disease today?
*
I can't leave my house
I can't work and perform my daily duties for days
I can work but sometimes I feel very bad for the whole day
I can work and perform my daily duties normally
Other
Required
Please, point any other symptoms that are not in this list!
Your answer
Thank you for your participation!
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
