This is a form to evaluate Post-COVID Infection Syndrome, also known as Long COVID. Post-COVID Infection Syndrome applies to those who had a COVID infection and who were never fully recovered from it after three months. The typical symptoms are (1) feeling fatigued most of the time, especially after physical activity and (2) “brain fog,” a feeling of inability to think clearly. In addition to these symptoms, there may be other chronic symptoms involving other parts of the body. Many of these same symptoms can also occur as the result of a COVID-19 vaccine injury, in which we call it Post-COVID Vaccine Injury Syndrome. The two syndromes have similar symptoms since both are probably caused by the persistence of the inflammatory COVID spike protein in various organs of the body, whether the spike protein came from a COVID infection or a COVID vaccine. The persistent spike protein then causes inflammation in various organs, including the heart, lungs, brain, and the blood vessels of those organs. Treatment aims to clear the spike protein and, in the meantime, reduce the inflammation caused by the remaining spike protein. Because the two syndromes are so similar and because many people have persistent spike protein from both infection and vaccination, we often just call it Post-COVID Syndrome. If you think that your symptoms are related to a COVID infection from which you never fully recovered, continue with this form. If your symptoms started after a COVID-19 vaccination without an identifiable COVID infection, go back to the website and use that form. If you are not sure what caused your symptoms but you have had a COVID vaccine, use the Post-COVID Vax Injury form.

Demographics

Patient First Name
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Patient Last Name
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Patient Street Address
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Patient City
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Patient State
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AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
Patient Zip Code
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Patient Birthdate
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Patient Age


Patient Phone
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Patient Email
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Patient Sex
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Female
Male

COVID History

How many times do you think that you have had a COVID-19 infection, regardless of any test results?
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One
Two
Three
Four
Five or more
How many COVID-like illnesses have you had during which you tested positive for COVID-19 infection?
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None
One
Two
Three
Four
Five or more
How many months ago did you have your most recent COVID-19 infection?
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Your age (in years) at the time of your last COVID infection
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How fully have you recovered from that most recent COVID infection?
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Fully recovered
Mostly recovered
Somewhat improved but still can’t perform my usual tasks
Not at all recovered
Recovered fully but then relapsed
Recovered somewhat but then relapsed
Now worse than when I had that last COVID infection
When were you first treated for your most recent COVID-19 infection?
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Within the first 24 hours
Within the first 24 to 48 hours
Between day two to five
Between day five to ten
After more than ten days
Never treated for my acute COVID-19 infection
Were you hospitalized for your COVID-19 infection?
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No
Emergency room only
Yes, for five days or less
Yes, for five to ten days
Yes, for more than ten days
Were you hospitalized in intensive care for your COVID-19 infection?
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No
1-2 days
3-5 days
6-10 days
more than 10 days
Did you require a mechanical ventilator to breathe when you hospitalized in intensive care for your COVID-19 infection?
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No
1-2 days
3-5 days
6-10 days
More than 10 days
Did you receive any prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply.
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Paxlovid (nirmatrelvir / ritonavir)
Ivermectin
Hydroxychloroquine
Azithromycin
Molnupiravir (Lagevrio)
Remdesivir (Veklury)
Tocilizumab (Actemra)
Anakinra (Kineret)
Baricitinib (Olumiant)
Vilobelimab (Gohibic)
Convalescent plasma
Other
None of the above
Did you receive any non-prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply
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Acetaminophen (Tylenol)
Aspirin
Ibuprofen (Advil, Motrin)
Vitamin C
Vitamin D
Zinc
Famotidine (Pepcid)
None of the above
How long after you started treatment was it until you began to feel better?
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Within the first 24 hours
Within the first 24 to 48 hours
Between day two to five
Between day five to ten
More than ten days
Never improved

Review Of Symptoms Following Long COVID That You Have One Or More Months After Your Acute COVID Infection

General Symptoms (check all that apply)
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Tiredness or fatigue that interferes with daily life Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)
Excessive sleep
Loss of sense of taste or smell
Other-make comment below
None of the above
Neurological symptoms (check all that apply)
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Mild memory loss
Moderate memory loss
Marked Memory Loss
Severe memory loss
Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
Headache
Sleep problems, insomnia
Dizziness when you stand up (lightheadedness)
Pins-and-needles feelings
Alzheimer’s symptoms
New or worsened multiple sclerosis
Guillain-Barre Syndrome
Bell’s palsy
Other-make comment below
None of the above
Psychological symptoms (check all that apply)
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Depression
Generalized anxiety
Post-traumatic stress disorder
Panic disorder
Other-make comment below
None of these
Decreased mobility due to pain or arthritis of hands, back, hips, or knees
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No decrease on mobility
Mildly decreased mobility
Moderately decreased mobility
Markedly decreased mobility
Severely decreased mobility
Other-make comment below
Heart symptoms (check all that apply)
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Resting heart rate 60 to 70
Resting heart rate 70 to 80
Resting heart rate 80 to 90
Resting heart rate 90 to 100
Resting heart rate 100 to 110
Resting heart rate 110 to 120
Heart rate after walking a short distance 70-80
Heart rate after walking a short distance 80-90
Heart rate after walking a short distance 90-100
Heart rate after walking a short distance 100-110
Heart rate after walking a short distance 110-120
Dizziness or low blood pressure upon standing up
New abnormal heart rhythm, atrial fibrillation since COVID infection
New heart failure since COVID infection
New coronary stents placed since COVID infection
POTS Syndrome (postural orthostatic tachycardia syndrome)
Other-make comment below
None of the above
Respiratory symptoms (check all that apply)
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Mild dry cough
Mild wet cough
Moderate dry cough
Moderate wet cough
Severe dry cough
Severe wet cough
Out of breath at rest
breath at rest • Out of breath after short walk
Other-make comment below
None of the above
Blood clotting disorders (check all that apply)
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Blood clot in one lower leg
Blood clots in both lower legs
Stroke
Other-make comment below
Digestive symptoms (click all that apply)
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New onset of inflammatory bowel disease (lupus, inflammatory bowel disease)
Other-make comment below
None of the above
New onset autoimmune symptoms (click all that apply)
Psoriasis, Psoriatic Arthritis
Inflammatory bowel disease
Systemic lupus erythematosus
Polyarthralgia/polyarthritis
Inflammatory myositis
Red rash
Epstein-Barr viral reactivation
CMV reactivation
Herpes Simplex reactivation
Reproductive symptoms (check all that apply)
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Menstrual irregularity
Amenorrhea (absence of menses)
Menorrhagia (unusually heavy bleeding)
Premature ovarian failure
Other-make comment below
None of the above
New or recurrent cancer
Yes, describe below in Comments
No
How many COVID vaccines have you had?
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None
One of initial series
Two (initial series)
Initial series plus one booster
Initial series plus two boosters
Initial series plus three or more boosters
Which initial series did you have?
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Pfizer
Moderna
Astra Zeneca
Johnson & Johnson
None
Do You Have Any Comments You Wish To Add?

General Health

Please list all of your chronic medical problems besides your Post-COVID Infection Syndrome:


Please list all the times you have had to stay in a hospital overnight, the main reason you were there, and how long you were there:


Please list all the surgical procedures or operations for which you have to be sedated or put to sleep, the dates of those surgeries, and any complications:


Please list all the prescription drugs that you are taking at this time and the reasons that you take them:


Please list all the drugs and foods to which you are allergic:

Social History

Do you have a spouse or significant other relationship at this time?
Yes
No
Spouse or significant other’s first name


Spouse or significant other’s last name


Are you employed, attending school, or doing volunteer work at this time?
Employed full time
Employed part time
Attending school full time
Attending school part time
Doing volunteer work full time
Doing volunteer work part time
None of the above
Briefly, what kind of employment do you have at this time?


Briefly, what kind of school do you attend at this time?


Briefly, what kind of volunteer work do you do at this time?


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