Protocol - Long COVID - Symptoms Due to COVID-19 - Memory
A self-administered questionnaire to better describe and understand the patient experience and recovery of those with confirmed or suspected COVID-19, with a specific emphasis on Long COVID experience especially with memory.
1. Have you experienced any MEMORY RELATED SYMPTOMS since the start of your COVID-19 illness?
[ ] Yes
[ ] No
2. Which of the following memory symptoms have you experienced since the start of your COVID-19 illness?
[ ] Short-term memory loss (memory that lasts ~30 seconds, i.e. remembering a phone number before writing it down, or forgetting youre in the middle of a task)
[ ] Long-term memory loss (long-term memory can be anything from remembering yesterday, forgetting youve done a task, forgetting recently learned information, or forgetting your third-grade experience)
[ ] Not being able to make new memories
[ ] Forgetting how to do routine tasks (tying your shoe laces, washing your hands)
[ ] None of the above
[ ] Other __________
3. When did you experience these symptoms?
Please mark symptoms for the first 4 weeks, then months (if applicable). Even if you have only experienced these symptoms for part of a week or month, please select it.
Cognitive Function/Brain Fog Symptoms
4. Have you experienced issues with BRAIN FOG (inability to focus, think clearly, plan, process, understand, and maintain a coherent stream of thought; abnormally slow or fast thoughts) since the start of your COVID-19 illness?
[ ] Yes
[ ] No
5. Which of the following brain fog/cognitive functioning symptoms have you experienced since the start of your COVID-19 illness?
[ ] Difficulty with executive functioning (planning, organizing, figuring out the sequence of actions, abstracting)
[ ] Agnosia (failure to recognize or identify objects despite intact sensory functioning)
[ ] Difficulty problem-solving or decision-making
[ ] Difficulty thinking
[ ] Thoughts moving too quickly
[ ] Slowed thoughts
[ ] Poor attention or concentration
[ ] I did NOT have any Brain Fog symptoms
[ ] Other
6. When did you experience these symptoms?
Please mark symptoms for the first 4 weeks, then months (if you havent yet reached a week/month, please leave it blank). Even if you have only experienced these symptoms for part of a week or month, please select it.
Brain fog/cognitive functioning symptoms
Changes to Daily/Functional Abilities due to memory loss or brain fog
7. Have you felt significantly limited or unable to do any of the following due to MEMORY LOSS OR BRAIN FOG (including issues with attention, cognitive functioning, and awareness) specifically?
Cook or use hot items
Shower or bathe regularly
Make serious decisions
Leave the house and return without getting lost
Remember the correct month or year
Have conversations with others
Maintain your medication schedule (forgetting to take medication or forgetting youve taken medication)
Follow simple instructions
Communicate your thoughts and needs
8. Optional: If you have other areas of your life that were affected by memory loss or brain fog, please include them here. Please note whether they were mildly, moderately, or severely limiting.
9. Optional: Please use this space to describe examples of your brain fog, memory loss, and attention span.
Please do not include any identifying information (such as name or location).
Personnel and Training Required
|Specialized requirements for biospecimen collection||No|
|Average time of greater than 15 minutes in an unaffected individual||No|
Mode of Administration
Adults suffering COVID-19 or suspected COVID-19 infection symptoms for longer than 1 week
The Memory module extracted from the Online Survey on Recovery from COVID-19 is brief and easy to interpret. This protocol is also available in a wide variety of languages.
English, Other languages available at source
Process and Review
Protocol Name from Source
Online Survey on Recovery from COVID-19
Davis, H., Assaf, G., McCorkell, L., Wei, H., Low, R., Re'em, Y., & Akrami, A. (2021). Questionnaire to Characterize Long COVID: 200+ symptoms over 7 months (in 9 languages) (Version 4). figshare. https://doi.org/10.6084/m9.figshare.13642553.v4 (['http://patientresearchcovid19.com/'])
|Variable Name||Variable ID||Variable Description||dbGaP Mapping|
|PX992002040000||Have you experienced issues with BRAIN FOG more||N/A|
|PX992002060000||When did you experience these symptoms? more||N/A|
|PX992002050000||Which of the following brain fog/cognitive more||N/A|
|PX992002090000||Optional: Please use this space to describe more||N/A|
|PX992002020000||Which of the following memory symptoms have more||N/A|
|PX992002020100||Which of the following memory symptoms have more||N/A|
|PX992002071300||Have you felt significantly limited or more||N/A|
|PX992002070900||Have you felt significantly limited or more||N/A|
|PX992002070300||Have you felt significantly limited or more||N/A|
|PX992002070100||Have you felt significantly limited or more||N/A|
|PX992002070400||Have you felt significantly limited or more||N/A|
|PX992002071200||Have you felt significantly limited or more||N/A|
|PX992002070700||Have you felt significantly limited or more||N/A|
|PX992002071000||Have you felt significantly limited or more||N/A|
|PX992002070600||Have you felt significantly limited or more||N/A|
|PX992002071400||Have you felt significantly limited or more||N/A|
|PX992002071401||Have you felt significantly limited or more||N/A|
|PX992002070800||Have you felt significantly limited or more||N/A|
|PX992002070500||Have you felt significantly limited or more||N/A|
|PX992002070200||Have you felt significantly limited or more||N/A|
|PX992002071100||Have you felt significantly limited or more||N/A|
|PX992002010000||Have you experienced any MEMORY RELATED more||N/A|
|PX992002080000||Optional: If you have other areas of your more||N/A|
|PX992002030000||When did you experience these symptoms? more||N/A|
Long COVID - Symptoms Due to COVID-19
March 17, 2023
This is a measure of an individual’s new or continuing COVID-19 symptoms.
Presence of lingering COVID-19 symptoms is a sign of Long COVID, and use of this measure helps with understanding people’s experience with COVID-19 and implications of Long COVID.
long covid - symptoms due to covid-19 - memory, University College London, UCL, COVID, long COVID, memory, cognitive function, brain fog, daily or function ability changes
There are no publications listed for this protocol.