Long Covid Assessment - SBQ-LC Version 1

Symptom Burden QuestionnaireTM
First and Last Name*
Email*
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Birthdate*

MonthDayYear
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Phone Number*
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Date of Administration (Today's Date)*

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The Symptom Burden Questionnaire TM for Long COVID (SBQ TM -LC) asks for your views about your symptoms and their impact on daily life over the last 7 days. It will take approximately 15-20 minutes to complete all the scales. For each scale, please answer ALL the questions. Please rest and take breaks if needed. Thank you for completing this questionnaire.

NIHR|National Institutefor Health Research
© 2021 The University of Birmingham I All rights reserved
BREATHING
These questions are about your BREATHING symptoms. For each question, please choose the response that best describes your experience over the last 7 days.
In the last 7 days, how severe was your shortness of breath (difficulty breathing) when sitting at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your shortness of breath (difficulty breathing) when climbing a flight of stairs at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your shortness of breath (difficulty breathing) when lying flat at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you wake up at night short of breath? (0 - No, 1 - Yes)*

0

1

0 is No, 1 is Yes
In the last 7 days, was your breathing faster than usual? (0 - No, 1 - Yes)*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was the tightness of your chest at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your wheezing (noisy breathing) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Breathing Calculation
PAIN
These questions are about your PAIN symptoms. For each question, please choose the response that best describes your experience over the last 7 days.
In the last 7 days, how severe was your chest pain at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your pain on breathing at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your shooting or stabbing pain in any place on your body at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your aching or burning pain in any place on your body at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Pain Calculation
CIRCULATION
These questions are about your CIRCULATION symptoms. For each question, please choose the response that best describes your experience over the last 7 days.
In the last 7 days, how severe were your palpitations (feeling like your heart skipped a beat or a pounding heartbeat) at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you feel faint? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your dizziness on standing at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was the swelling of your legs and/or feet at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have cold hands/feet that lasted for longer or were colder than usual? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
Circulation Calculation
FATIGUE
These questions are about your FATIGUE symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your fatigue (feeling of physical or mental exhaustion that does not improve with rest) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your low energy (being interested and wanting to do things but not having the energy)? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your tiredness (need for sleep) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was the worsening of your symptoms following simple physical or mental activities at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Fatigue Calculation
MEMORY, THINKING AND COMMUNICATION
These questions are about your MEMORY, THINKING, AND COMMUNCATION symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your difficulty remembering things at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your memory loss at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your brain fog (feeling sluggish, jet-lagged, or blanking out) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how often did you feel confused about what was happening around you? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how often did you have difficulty concentrating? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your difficulty planning at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your word-finding difficulty (unable to think of the word you want to say or write) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your difficulty understanding what others were saying at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your slurred speech at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your reading difficulty (not related to dyslexia)? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Memory, Thinking and Communication Calculation
MOVEMENT
These questions are about your MOVEMENT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your tremor (uncontrollable shaking or trembling in part of your body) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your balance difficulty at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your difficulty with movement and coordination at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Movement Calculation
SLEEP
These questions are about your SLEEP symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how often did you have problems falling asleep? (0 - Never, 1 - Rarely, 2 - Sometimes, 3 - Often)*

0

1

2

3

0 is Never, 3 is Often
In the last 7 days, how often was your sleep shorter than usual? (0 - Never, 1 - Rarely, 2 - Sometimes, 3 - Often)*

0

1

2

3

0 is Never, 3 is Often
In the last 7 days, how often was your sleep interrupted? (0 - Never, 1 - Rarely, 2 - Sometimes, 3 - Often)*

0

1

2

3

0 is Never, 3 is Often
In the last 7 days, how often did you sleep longer than usual? (0 - Never, 1 - Rarely, 2 - Sometimes, 3 - Often)*

0

1

2

3

0 is Never, 3 is Often
Sleep Calculation
EARS, NOSE AND THROAT
These questions are about your EAR, NOSE, AND THROAT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your altered sense of smell (foods/objects smelling different to usual) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your altered sense of taste (foods tasting different to usual) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your sneezing at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your stuffy or runny nose at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your sinus congestion (discomfort or feeling of 'fullness' around nose, cheeks, forehead, or around the eyes) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your production of mucus (phlegm) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your cough at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your sore throat at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your hoarse voice (change in your voice quality) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have difficulty swallowing food or drink? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your earache (ear pain) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have new hearing loss? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your tinnitus (noises or ringing sounds in your ears) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your sensitivity to sounds that were not a problem for others (everyday sounds were uncomfortably loud and/or painful) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Ear, Nose and Throat Calculation
STOMACH AND DIGESTION
These questions are about your STOMACH AND DIGESTION symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your belly/tummy pain at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was the bloating of your belly/tummy area at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your nausea (urge to vomit) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your indigestion and/or heartburn at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, have you been worried about your unplanned weight loss? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
In the last 7 days, have you been worried about your unplanned weight gain? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your diarrhea at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your constipation (bowel movements happen less often than normal) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Stomach and Digestion Calculation
MUSCLES AND JOINTS
These questions are about your MUSCLE AND JOINT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your muscle pain at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your muscle weakness at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your muscle stiffness at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your joint pain at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your joint swelling at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your joint stiffness at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your muscle twitching at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your muscle cramping at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was the tingling and numbness (pins and needles) in your arms and legs at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Muscle and Joint Calculation
MENTAL HEALTH AND WELLBEING
These questions are about your MENTAL HEALTH AND WELLBEING symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your lack of interest in things around you at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your anxiety at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe were your feelings of sadness and being miserable at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have thoughts about harming yourself in any way? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe were your mood swings at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your change in appetite at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how often did you feel lonely or unsupported? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is Never, 3 is Always
In the last 7 days, how often did you feel hopeful about the future? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe) (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is Never, 3 is Always
In the last 7 days, did you feel like the person you were before having COVID-19? *

0

1

0 is No, 1 is Yes
Mental Health and Wellbeing Calculation
SKIN AND HAIR
These questions are about your SKIN AND HAIR symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your dry skin at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe) *

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your scaly skin at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe) *

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your itchy skin at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe) *

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have purple-red spots on your feet? *

0

1

0 is No, 1 is Yes
In the last 7 days, did you have a rash? *

0

1

0 is No, 1 is Yes
In the last 7 days, did you have hives (welts or raised itchy patches of skin)? *

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your hair loss at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe were the changes to your nails (ridging, pitting, discoloration, or brittle nails) at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Skin and Hair Calculation
EYES
These questions are about your EYE symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.
In the last 7 days, did you have red or bloodshot eyes? *

0

1

0 is No, 1 is Yes
In the last 7 days, did you have dry eyes?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you have itchy eyes?*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your blurred vision and/or double vision (not related to wearing glasses) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how often did you have flashing lights and/or floaters (small dark shapes that float across your vision)? (0 - Never, 1 - Rarely, 2 - Sometimes, 3 - Always)*

0

1

2

3

0 is Never, 3 is Always
In the last 7 days, how severe was your sensitivity to light at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have watery eyes (excessive tears)?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you have a feeling of pressure behind your eyes?*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was the feeling of pain behind your eyes at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how often did you have a feeling of something rubbing against your eye when you blink (foreign body sensation)? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is Never, 3 is Always
Eye Calculation
FEMALE REPRODUCTIVE AND SEXUAL HEALTH
These questions are about your FEMALE REPRODUCTIVE AND SEXUAL HEALTH symptoms. Please answer ALL the questions thinking about your symptoms over the last 7 days.
In the last month, did you have unusual changes to your menstrual period (irregular, missed, or unexpected period)?

0 - No1 - YesNot Applicable
In the last month, was your premenstrual syndrome (PMS) worse than usual?

0 - No1 - YesNot Applicable
In the last month, did you pass blood clots during your period more than usual?

0 - No1 - YesNot Applicable
In the last 7 days, how severe was your vaginal dryness at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your vaginal discharge at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, were you worried about your ability to have an orgasm or climax?

0 - No1 - YesNot Applicable
In the last 7 days, how severe was your decreased interest in sex at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Female Reproductive & Sexual Health Calculation
MALE REPRODUCTIVE AND SEXUAL HEALTH
These questions are about your MALE REPRODUCTIVE AND SEXUAL HEALTH symptoms. Please answer ALL the questions thinking about your symptoms over the last 7 days.
In the last 7 days, how severe was your difficulty getting or keeping an erection at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have difficulty with ejaculation?

0 - No1 - Yes
In the last 7 days, did you have a decreased interest in sex?

0 - No1 - Yes
Male Reproductive & Sexual Health Calculation
OTHER SYMPTOMS
These questions are about your OTHER SYMPTOMS. Please answer ALL the questions thinking about your symptoms over the last 7 days.
In the last 7 days, did you have a fever?*

0

1

0 is No, 1 is Yes
In the last 7 days, how often did you have chills/shivering?*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your sweating problem at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is Never, 3 is Always
In the last 7 days, how severe were your hot flushes at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your aching all over the body at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was the swelling of your glands (lymph nodes) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your vertigo (when everything around you was spinning enough to affect your balance) at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you have swelling of your face, lips, tongue, and/or throat?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you experience a heightened reaction to known allergies?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you experience a heightened reaction to new allergies?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you have loss of control of urine (leakage)?*

0

1

0 is No, 1 is Yes
In the last 7 days, did you have difficulty passing urine?*

0

1

0 is No, 1 is Yes
In the last 7 days, have you been passing more urine than usual?*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your increased thirst at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe were your mouth ulcers at their worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, did you experience a worsening of known dental problems?*

0

1

0 is No, 1 is Yes
In the last 7 days, how severe was your dry mouth at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
In the last 7 days, how severe was your headache at its worst? (0 - None, 1 - Mild, 2 - Moderate, 3 - Severe)*

0

1

2

3

0 is None, 3 is Severe
Other Symptoms Calculation
IMPACT ON DAILY LIFE
For EACH question, please select one answer that best describes how your symptoms have affected you in the last 7 days. Please answer ALL the questions.
In the last 7 days, have your symptoms affected your ability to work, volunteer, go to school or take part in organised activities? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to go shopping? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to do housework or light chores? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to move around easily? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to look after yourself (bathing and dressing)? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your relationships with others (friends and family)? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to socialise and interact with others? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
In the last 7 days, have your symptoms affected your ability to enjoy life? (0 - Not At All, 1 - Very Little, 2 - Somewhat, 3 - Severely)*

0

1

2

3

0 is Not At All, 3 is Severely
Impact on Daily Life Calculation
OTHER SYMPTOMS
Do you have any other symptoms you wish to report?*

0

1

0 is No, 1 is Yes
If YES, which other symptom(s) do you wish to report? (Please describe each symptom on a new row):
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
SYMPTOM
In the last 7 days, what was the severity of this symptom at its worst?

1 - Mild2 - Moderate3 - Severe
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BREATHING

PAIN

CIRCULATION

FATIGUE

MEMORY, THINKING AND COMMUNICATION

MOVEMENT

SLEEP

EARS, NOSE AND THROAT

STOMACH AND DIGESTION

MUSCLES AND JOINTS

MENTAL HEALTH AND WELLBEING

SKIN AND HAIR

EYES

FEMALE REPRODUCTIVE AND SEXUAL HEALTH

MALE REPRODUCTIVE AND SEXUAL HEALTH

OTHER SYMPTOMS

IMPACT ON DAILY LIFE

OTHER SYMPTOMS