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Protocol - COVID-19 Related Health Questions

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Description

A questionnaire to determine COVID related symptoms experienced, diagnosis of COVID-19, dates to determine start of COVID related symptoms and medical attention received.

Specific Instructions

The calendar in question 1 may be extended monthly as needed.

Protocol

1. We are interested in whether you have experienced any symptoms listed below since November 2019. Please complete the table for any of the symptoms you have had and in what month(s) you had them. Please complete for any symptoms and any months that symptoms were experienced irrespective of whether or not you saw a doctor and irrespective of whether or not you were told you had flu, or coronavirus disease 2019 (COVID-19) or any other diagnosis

Nov 2019

Dec 2019

Jan 2020

Feb 2020

Mar 2020

Apr 2020

Last week

No cold or flu symptoms

Decrease in appetite

Nausea and/or vomiting

Diarrhoea

Abdominal pain/tummy ache

Runny nose

Sneezing

Blocked nose

Sore eyes

Loss of sense of smell

Loss of sense of taste

Sore throat

Hoarse voice

Headache (if more often or worse than usual)

Dizziness

Shortness of breath affecting normal activities

New persistent cough

Tightness in the chest

Chest pain

Fever (feeling too hot)

Chills (feeling too cold)

Difficulty sleeping

Felt more tired than normal

Severe fatigue (e.g. inability to get out of bed)

Numbness or tingling somewhere in the body

Feeling of heaviness in arms or legs

Achy muscles


2. If you have had any of the symptoms above in the last week:

   2a. when did the first one start?

      [ ] 1 day ago

      [ ] 2 days ago

      [ ] 3 days ago

      [ ] 4 days ago

      [ ] 5 days ago

      [ ] 6 days ago

      [ ] 7 days ago

      [ ] Can’t remember

   2b. when did the last one finish?

      [ ] 1 day ago

      [ ] 2 days ago

      [ ] 3 days ago

      [ ] 4 days ago

      [ ] 5 days ago

      [ ] 6 days ago

      [ ] 7 days ago

      [ ] Can’t remember

      [ ] I still have it/them

   2c. In the last week have you had shortness of breath (difficulty breathing)?

      [ ] No

      [ ] Yes, but did not affect my normal activities

      [ ] Yes, did affect my normal activities (e.g. walking short distances)

      [ ] Yes, even when I was sat or lying down

   2d. Did you seek medical attention for the symptoms you had in the last week?

      [ ] Yes

      [ ] No

   If 2d = No, skip to question 3

   2e. If yes, what kind of medical attention did you access? [tick all that apply]

      [ ] Contacted NHS 111, by phone or online

      [ ] Visited pharmacist

      [ ] Consulted GP/practice nurse over the phone or online

      [ ] Consulted GP/practice nurse face to face

      [ ] Walk-in centre

      [ ] Accident and Emergency

      [ ] Other, please specify _______

3.

   3a. In the last week have you had your temperature taken?

      [ ] Yes

      [ ] No

   If 3a = No, skip to question 4

   3b. Who took your temperature?

      [ ] A doctor/nurse or other health professional

      [ ] I did

      [ ] It was taken by someone else

   3c. If you can remember, what was the highest temperature reading?

   _ _ . _ C

4. Have you been in close contact with anyone with COVID-19 in the last two weeks?

[ ] Yes, I was in contact with a confirmed/tested COVID-19 case

[ ] Yes, I was in contact with a suspected COVID-19 case

[ ] No, not to my knowledge

5.

   5a. Do you think that you have or have had COVID-19?

[ ] Yes, confirmed by a positive test

[ ] Yes, suspected by a doctor but not tested

[ ] Yes, my own suspicions

[ ] No

   If 5a = No, go to question 6

   5b. If yes, when were you told/when did you think you first had COVID-19?

   _ _ / _ _ / _ _ _ _ (DD/MM/YY)

6.

   6a. Are you, or do you, currently have any of the following? (tick all that apply)

Tick if yes

Organ transplant recipient

Diabetes (Type I or II)

Heart disease or heart problems

Hypertension (high blood pressure)

Overweight

Stroke

Kidney disease

Liver disease

Anaemia

Asthma

Other lung condition such as COPD, bronchitis or emphysema

Cancer

Condition affecting the brain and nerves (e.g. Dementia, Parkinson’s, Multiple Sclerosis)

A weakened immune system/reduced ability to deal with infections (as a result of a disease or treatment)

Depression

Anxiety

Psychiatric disorder

   6b. If yes, please tell us exactly what you have:

   ___________________

   6c. Have you been contacted by letter or text message to say you are at severe risk from COVID-19 due to an underlying health condition and should be shielding (avoiding exposure)?

1[ ]Yes

2[ ]No

7. For each of the following questions please respond Yes or No

Yes

No

In general, do you have health problems that require you to limit your activities?

Do you need someone to help you on a regular basis?

In general, do you have any health problems that require you to stay at home?

If you need help, can you count on someone close to you?

Do you regularly use a stick, walker or wheelchair to move about?

8. Do you currently take any regular medication?

[ ] Yes

[ ] No

9. Have you had a flu jab (flu shot) in the last 12 months?

[ ] Yes

[ ] No

Availability

Available

Personnel and Training Required

Equipment Needs

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Interviewer-administered questionnaire

Lifestage

Infant, Toddler, Child, Adolescent, Adult, Senior, Pregnancy

Participants

Not specified

Selection Rationale

PhenX used input from crowdsourcing to enable rapid response and release of COVID-19 related protocols in the Toolkit. 

Language

English

Standards
StandardNameIDSource
caDSR Common Data Elements (CDE) COVID-19 Health Questionnaire Assessment Text   7484963 CDE Browser
Derived Variables

Process and Review

Not applicable

Protocol Name from Source

UK COVID-19 Questionnaire

Source

UK Covid-19 Questionnaire. Version 23 April 2020, Core Questionnaire, questions 1-9.

General References

Protocol ID

940101

Variables
Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
PX940101_Covid19_Health_Questions_Contact_Covid19_Last_Two_Weeks
PX940101040000 Have you been in close contact with anyone more
with COVID-19 in the last two weeks? show less
N/A
PX940101_Covid19_Health_Questions_Flu_Shot
PX940101090000 Have you had a flu jab (flu shot) in the more
last 12 months? show less
N/A
PX940101_Covid19_Health_Questions_Health_Condition
PX940101060100 Are you, or do you have, any of the more
following? (tick all that apply) show less
N/A
PX940101_Covid19_Health_Questions_Health_Condition_Yes
PX940101060200 If yes, please tell us exactly what you have N/A
PX940101_Covid19_Health_Questions_Health_Help_Close
PX940101070500 If you need help, can you count on someone more
close to you? show less
N/A
PX940101_Covid19_Health_Questions_Health_Help_Regular
PX940101070300 Do you need someone to help you on a regular more
basis? show less
N/A
PX940101_Covid19_Health_Questions_Health_Move_Assistance
PX940101070600 Do you regularly use a stick, walker or more
wheelchair to move about? show less
N/A
PX940101_Covid19_Health_Questions_Health_Problems_Limit
PX940101070200 In general, do you have health problems that more
require you to limit your activities? show less
N/A
PX940101_Covid19_Health_Questions_Health_Problems_Stay_Home
PX940101070400 In general, do you have any health problems more
that require you to stay at home? show less
N/A
PX940101_Covid19_Health_Questions_Last_Week_Temperature
PX940101030100 In the last week have you had your more
temperature taken? show less
N/A
PX940101_Covid19_Health_Questions_Last_Week_Temperature_Reading
PX940101030300 If you can remember, what was the highest more
temperature reading? (degrees C) show less
N/A
PX940101_Covid19_Health_Questions_Last_Week_Temperature_Who
PX940101030200 Who took your temperature? N/A
PX940101_Covid19_Health_Questions_Medication_Regular
PX940101080000 Do you currently take any regular medication? N/A
PX940101_Covid19_Health_Questions_Message_Risk_Covid
PX940101070100 Have you been contacted by letter or text more
message to say you are at severe risk from COVID-19 due to an underlying health condition and should be shielding (avoiding exposure)? show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Ache_Muscle
PX940101012700 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Achy muscles show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Blocked_Nose
PX940101010800 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Blocked nose show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Chest_Pain
PX940101011900 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Chest pain show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Chill
PX940101012100 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Chills (feeling too cold) show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Decreased_Appetite
PX940101010200 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Decrease in appetite show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Diarrhoea
PX940101010400 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Diarrhoea show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Difficulty_Sleep
PX940101012200 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Difficulty sleeping show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Dizzy
PX940101011500 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Dizziness show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Fatigue
PX940101012400 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Severe fatigue (e.g. inability to get out of bed) show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Fever
PX940101012000 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Fever (feeling too hot) show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Headache
PX940101011400 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Headache (if more often or worse than usual) show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Heaviness_Arm_Leg
PX940101012600 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Feeling of heaviness in arms or legs show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Hoarse
PX940101011300 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Hoarse voice show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Loss_Smell
PX940101011000 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Loss of sense of smell show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Loss_Taste
PX940101011100 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Loss of sense of taste show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Nausea
PX940101010300 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Nausea and/or vomiting show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_None
PX940101010100 We are interested in whether you have more
experienced any symptoms listed below since November 2019. No cold or flu symptoms show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Numbness
PX940101012500 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Numbness or tingling somewhere in the body show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Other
PX940101020502 If yes, what kind of medical attention did more
you access? Other, please specify show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Past_Week_Days_Finish
PX940101020200 If you have had any of the symptoms above in more
the last week, when did the last one finish? show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Past_Week_Days_Start
PX940101020100 If you have had any of the symptoms above in more
the last week, when did the first one start? show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Past_Week_Medical_Attention
PX940101020400 Did you seek medical attention for the more
symptoms you had in the last week? show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Past_Week_Medical_Attention_Type
PX940101020501 If yes, what kind of medical attention did more
you access? [tick all that apply] show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Past_Week_Short_Breath
PX940101020300 In the last week have you had shortness of more
breath (difficulty breathing)? show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Persistent_Cough
PX940101011700 We are interested in whether you have more
experienced any symptoms listed below since November 2019. New persistent cough show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Runny_Nose
PX940101010600 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Runny nose show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Short_Breath
PX940101011600 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Shortness of breath affecting normal activities show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Sneeze
PX940101010700 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Sneezing show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Sore_Eyes
PX940101010900 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Sore eyes show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Sore_Throat
PX940101011200 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Sore throat show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Stomach_Pain
PX940101010500 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Abdominal pain/tummy ache show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Tight_Chest
PX940101011800 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Tightness in the chest show less
N/A
PX940101_Covid19_Health_Questions_Symptoms_Tire
PX940101012300 We are interested in whether you have more
experienced any symptoms listed below since November 2019. Felt more tired than normal show less
N/A
PX940101_Covid19_Health_Questions_Think_Have_Covid
PX940101050100 Do you think that you have or have had COVID-19? N/A
PX940101_Covid19_Health_Questions_Think_Have_Covid19_Date
PX940101050200 If yes, when were you told/when did you more
think you first had COVID-19? show less
N/A
COVID-19 Research
Measure Name

COVID-19 Related Health Questions

Release Date

October 30, 2020

Definition

This questionnaire aims to collect information about any symptoms experienced, medical treatment received and diagnosis of COVID-19.

Purpose

To collect information on diagnostic testing administered, health complications, medications administered, additional care and the outcome of people diagnosed with COVID-19.

Keywords

COVID-related symptoms, diagnosis, testing, complications, medications, medical attention, coronavirus, COVID-19, COVID

Measure Protocols
Protocol ID Protocol Name
940101 COVID-19 Related Health Questions
Publications

There are no publications listed for this protocol.