Protocol - Long COVID - Daily Living

1. Climbing stairs and transferring

This includes any of the following: getting into/out of bed, standing up/sitting down in a chair, getting into/out of a car, getting on/off a toilet, stepping onto a curb.

 1a. Please state which activities, if any, have been impacted and describe

 how they have been impacted.

 _______________________

 (Ex: Prior to my illness, I would need to sit for a moment before rising out of

 bed independently. Now I require another persons help to get out of bed.)

2. Personal grooming and dressing

This includes any of the following: brushing/flossing teeth, denture care, skin care, shaving, putting on socks and shoes, taking off underwear, putting on pants, putting on a jacket.

 2a. Please state which activities, if any, have been impacted and describe

 how they have been impacted.

 _______________________

 (Ex: Prior to my illness, I would need to sit for a moment before rising out of

 bed independently. Now I require another persons help to get out of bed.)

3. Using the toilet and bathing

This includes any of the following: wiping your body with wipes, taking a shower or bath, scrubbing and rinsing your body, wiping after you use the toilet.

 3a. Please state which activities, if any, have been impacted and describe

 how they have been impacted.

 _______________________

 (Ex: Prior to my illness, I would need to sit for a moment before rising out of

 bed independently. Now I require another persons help to get out of bed.)

4. Doing household chores

This includes any of the following: food preparation, cooking, folding laundry, vacuuming the floor, making the bed, feeding pets, wiping a table, loading the dishwasher, tidying up a room.

 4a. Please state which activities, if any, have been impacted and describe

 how they have been impacted.

 _______________________

 (Ex: Prior to my illness, I would need to sit for a moment before rising out of

 bed independently. Now I require another persons help to get out of bed.)

5. Managing personal affairs

This includes any of the following: using the phone or computer, paying bills, scheduling a doctor appointment, managing medications, refilling a prescription, making a shopping list

 5a. Please state which activities, if any, have been impacted and describe

 how they have been impacted.

 _______________________

 (Ex: Prior to my illness, I would need to sit for a moment before rising out of

 bed independently. Now I require another persons help to get out of bed.)

6. Do you experience shortness of breath or fatigue when performing any activities in the following categories? Please select all that apply.

[ ] Climbing stairs or transferring

[ ] Personal grooming and dressing

[ ] Using the toilet and bathing

[ ] Doing household chores

[ ] Managing personal affairs

7. When you are climbing stairs or transferring, how often do you feel shortness of breath/fatigue?

[ ] 0-25% of the time

[ ] 25-50% of the time

[ ] 50-75% of the time

[ ] 75-100% of the time

8. When you are dressing or performing personal grooming, how often do you feel shortness of breath/fatigue?

[ ] 0-25% of the time

[ ] 25-50% of the time

[ ] 50-75% of the time

[ ] 75-100% of the time

9. When you are using the toilet or bathing, how often do you feel shortness of breath/fatigue?

[ ] 0-25% of the time

[ ] 25-50% of the time

[ ] 50-75% of the time

[ ] 75-100% of the time

10. When you are doing household chores, how often do you feel shortness of breath/fatigue?

[ ] 0-25% of the time

[ ] 25-50% of the time

[ ] 50-75% of the time

[ ] 75-100% of the time

11. When you are managing your personal affairs, how often do you feel shortness of breath/fatigue?

[ ] 0-25% of the time

[ ] 25-50% of the time

[ ] 50-75% of the time

[ ] 75-100% of the time