Protocol - COVID-19 Related Health Questions

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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.


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


Abdominal pain/tummy ache

Runny nose


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)


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 _______


   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


   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)


   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)



Kidney disease

Liver disease



Other lung condition such as COPD, bronchitis or emphysema


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)



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



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



Personnel and Training Required

Equipment Needs

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

Life Stage

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


Not specified

Selection Rationale

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



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


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

General References

Protocol ID


Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
COVID-19 Research
Measure Name

COVID-19 Related Health Questions

Release Date

October 30, 2020


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


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


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