Follow up Self Assessment - isaric4c/wiki GitHub Wiki

Variable / Field Name Section Header Field Type Field Label Choices or Calculations
flw_survey_completed_by dropdown Survey completed by: 1, Patient self-assessment ; 2, Telephone-led follow-up ; 3, In-clinic nurse/clinican or research-led follow-up
flw_desceased_lost radio Participant deceased or lost to follow-up? 1, Deceased ; 2, Lost to follow-up
flw_date_death text (date_dmy) Date of death
flw_date_deathnk radio Date of death unknown 1, Date of death unknown
flw_date_lost_flw text (date_dmy) Date lost to follow-up
flw_date_lost_flwnk radio Date lost to follow-up unknown 1, Date lost to follow-up unknown
flw_no_consent text CONSENT HAS NOT BEEN RECORDED FOR THIS PARTICIPANT - it needs to be done in the the Follow up consent form. Once this has been done and you return to this form, the questions in the survey will be visible.
flw_survey_date About you and your COVID-19 illness (if you're completing this survey on behalf of a child or adult that you care for, all the questions relate to their health and wellbeing) text (date_dmy) Date you did the survey (DD/MM/YYYY):
flw_date_symptoms text (date_dmy) Roughly what day did you first experience symptoms of COVID-19?
flw_covid19_adm yesno Were you admitted to hospital due to COVID-19? 1, Yes ; 0, No
flw_date_adm text (date_dmy) Roughly at what date were you first admitted to hospital?
flw_date_disch text (date_dmy) Roughly at what date were you first discharged from hospital?
flw_covid19_readm yesno Have you been re-admitted to hospital due to COVID-19? 1, Yes ; 0, No
flw_icu radio If admitted to hospital, were you ever admitted to intensive care (ICU/ITU)? 1, Yes ; 0, No ; 2, Not applicable
flw_hospitals text Name of hospital/s
flw_recovered About your health now radio Do you feel fully recovered from COVID-19? 1, Yes ; 0, No ; 2, Not sure
flw_fever radio Have you felt feverish recently? 1, Yes ; 0, No ; 2, Not sure
flw_last_fever dropdown If yes roughly when did you last feel feverish? 1, within last 7 days ; 2, between 1 to 2 weeks ago ; 3, between 2 to 4 weeks ago ; 4, between 1 to 2 months ago ; 5, between 2 to 3 months ago
flw_illness_cause checkbox If yes, what was the cause of your recent feverish illness? 1, flw_illness_cause___1 COVID-19 ; 2, flw_illness_cause___2 Other respiratory infection (cough/cold/sore throat) ; 3, flw_illness_cause___3 Stomach infection (diarrhoea/vomiting) ; 4, flw_illness_cause___4 Urinary infection ; 5, flw_illness_cause___5 Other: ; 6, flw_illness_cause___6 Unknown ; 7, flw_illness_cause___7 Prefer not to say
flw_illness_other_cause text specify (other cause of recent illness):
flw_diag_dvt Since having COVID-19, have you been diagnosed with any of these? radio Deep vein thrombosis (DVT, "Clot in leg") 1, Yes ; 0, No ; 99, Not answered
flw_diag_stroke radio Stroke or mini stroke/TIA 1, Yes ; 0, No ; 99, Not answered
flw_diag_pe radio Pulmonary embolism (PE, "Clot in lung") 1, Yes ; 0, No ; 99, Not answered
flw_diag_heart_attack radio Heart attack 1, Yes ; 0, No ; 99, Not answered
flw_diag_kidney radio Kidney problems 1, Yes ; 0, No ; 99, Not answered
flw_diag_other text Other condition (please specify)?
flw_headache Within the last seven days, have you had any of these symptoms? radio Headache 1, Yes ; 0, No ; 99, Not answered
flw_balance radio Problems with balance 1, Yes ; 0, No ; 99, Not answered
flw_cough radio Persistent cough 1, Yes ; 0, No ; 99, Not answered
flw_limb_weakness radio Weakness in limbs 1, Yes ; 0, No ; 99, Not answered
flw_loss_smell radio Loss of smell 1, Yes ; 0, No ; 99, Not answered
flw_pain_breathing radio Pain on breathing 1, Yes ; 0, No ; 99, Not answered
flw_loss_taste radio Loss of taste 1, Yes ; 0, No ; 99, Not answered
flw_chest_pains radio Chest pains 1, Yes ; 0, No ; 99, Not answered
flw_breathless radio Shortness of breath/breathlessness 1, Yes ; 0, No ; 99, Not answered
flw_palpitations radio Palpitations (heart racing) 1, Yes ; 0, No ; 99, Not answered
flw_muscle_pain radio Persistent muscle pain 1, Yes ; 0, No ; 99, Not answered
flw_weight_loss radio Weight loss 1, Yes ; 0, No ; 99, Not answered
flw_joint_pain radio Joint pain or swelling 1, Yes ; 0, No ; 99, Not answered
flw_appetite radio Loss of appetite 1, Yes ; 0, No ; 99, Not answered
flw_swollen_ankle radio Swollen ankle(s) 1, Yes ; 0, No ; 99, Not answered
flw_stomach_pain radio Stomach pain 1, Yes ; 0, No ; 99, Not answered
flw_nausea radio Nausea/vomiting 1, Yes ; 0, No ; 99, Not answered
flw_sleeping radio Problems sleeping 1, Yes ; 0, No ; 99, Not answered
flw_constipation radio Constipation 1, Yes ; 0, No ; 99, Not answered
flw_diarrhoea radio Diarrhoea 1, Yes ; 0, No ; 99, Not answered
flw_lesions_toes radio Lumpy lesions (purple/pink/bluish) on toes/COVID-toes? 1, Yes ; 0, No ; 99, Not answered
flw_urine radio Problems passing urine 1, Yes ; 0, No ; 99, Not answered
flw_skin_rash radio Skin rash 1, Yes ; 0, No ; 99, Not answered
flw_one_side radio Can't fully move and / or feel one side of your body or face? 1, Yes ; 0, No ; 99, Not answered
flw_dizziness radio Dizziness/light headedness 1, Yes ; 0, No ; 99, Not answered
flw_swallow radio Problems swallowing or chewing 1, Yes ; 0, No ; 99, Not answered
flw_seeing radio Problems seeing 1, Yes ; 0, No ; 99, Not answered
flw_other_symp radio Any other NEW symptoms? 1, Yes ; 0, No ; 99, Not answered
flw_fainting radio Fainting/ blackouts 1, Yes ; 0, No ; 99, Not answered
flw_new_symptoms text If yes (to any other NEW symptoms), specify:
flw_ed radio Erectile dysfunction 1, Yes ; 0, No ; 2, N/A
flw_cough_type radio If yes to Persistent cough - specify type: 1, dry cough ; 2, with phlegm
flw_rash_area checkbox If yes to Skin rash, please tick all body areas that apply: 1, flw_rash_area___1 Face ; 2, flw_rash_area___2 Trunk (stomach or back) ; 3, flw_rash_area___2 Trunk (stomach or back) ; 4, flw_rash_area___4 Legs ; 5, flw_rash_area___5 Buttocks ; 6, flw_rash_area___6 Toes ; 7, flw_rash_area___7 Fingers
flw_eq5d_mb_p About your health Under each heading, please tick the ONE box that best describes your health BEFORE Your COVID19 illness radio MOBILITY 1, I had no problems in walking about ; 2, I had slight problems in walking about ; 3, I had moderate problems in walking about ; 4, I had severe problems in walking about ; 5, I was unable to walk about
flw_eq5d_sc_p radio SELF-CARE 1, I had no problems washing or dressing myself ; 2, I had slight problems washing or dressing myself ; 3, I had moderate problems washing or dressing myself ; 4, I had severe problems washing or dressing myself ; 5, I was unable to wash or dress myself
flw_eq5d_ua_p radio USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) 1, I had no problems doing my usual activities ; 2, I had slight problems doing my usual activities ; 3, I had moderate problems doing my usual activities ; 4, I had severe problems doing my usually activities ; 5, I was unable to do my usual activities
flw_eq5d_pd_p radio PAIN/DISCOMFORT 1, I had no pain or discomfort ; 2, I had slight pain or discomfort ; 3, I had moderate pain or discomfort ; 4, I had severe pain or discomfort ; 5, I had extreme pain or discomfort
flw_eq5d_ad_p radio ANXIETY/DEPRESSION 1, I was not anxious or depressed ; 2, I was slightly anxious or depressed ; 3, I was moderately anxious or depressed ; 4, I was severely anxious or depressed ; 5, I was extremely anxious or depressed
flw_eq5d_mb Under each heading, please tick the ONE box that best describes your health TODAY radio MOBILITY 1, I have no problems in walking about ; 2, I have slight problems in walking about ; 3, I have moderate problems in walking about ; 4, I have severe problems in walking about ; 5, I am unable to walk about
flw_eq5d_sc radio SELF-CARE 1, I have no problems amhing or dressing myself ; 2, I have slight problems amhing or dressing myself ; 3, I have moderate problems amhing or dressing myself ; 4, I have severe problems amhing or dressing myself ; 5, I am unable to amh or dress myself
flw_eq5d_ua radio USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) 1, I have no problems doing my usual activities ; 2, I have slight problems doing my usual activities ; 3, I have moderate problems doing my usual activities ; 4, I have severe problems doing my usually activities ; 5, I am unable to do my usual activities
flw_eq5d_pd radio PAIN/DISCOMFORT 1, I have no pain or discomfort ; 2, I have slight pain or discomfort ; 3, I have moderate pain or discomfort ; 4, I have severe pain or discomfort ; 5, I have extreme pain or discomfort
flw_eq5d_ad radio ANXIETY/DEPRESSION 1, I am not anxious or depressed ; 2, I am slightly anxious or depressed ; 3, I am moderately anxious or depressed ; 4, I am severely anxious or depressed ; 5, I am extremely anxious or depressed
flw_eq5d5l_vas text • We would like to know how good or bad your health is TODAY. • This scale is numbered from 0 to 100. • 100 means the best health you can imagine. 0 means the worst health you can imagine. • Mark an X on the scale to indicate how your health is TODAY. • Now, please write the number you marked on the scale in the box below YOUR HEALTH TODAY =
eq5d5l_text text © EuroQol Research Foundation. EQ-5D™ is a trade mark of the EuroQol Research Foundation
flw_breathless_now Breathlessness and fatigue Please tick ONE box that best describes how breathless you feel and ONE box that describes how breathless you felt before your Covid 19 illness checkbox (Breathless) Within the last 24 hours 1, flw_breathless_now___1 Not troubled by breathlessness except on strenuous exercise ; 2, flw_breathless_now___2 Short of breath when hurrying or when walking up a slight hill ; 3, flw_breathless_now___3 Walks slower than most people of my age because of breathlessness, or have to stop for breath when walking at own pace ; 4, flw_breathless_now___4 Stops for breath after walking 100 yards/ 90-100 metres, or after a few minutes on level ground ; 5, flw_breathless_now___5 Too breathless to leave the house, or breathless when dressing/undressing
flw_breathless_pre_c19 checkbox (Breathless) Before your Covid 19 illness 1, flw_breathless_pre___1 Not troubled by breathlessness except on strenuous exercise ; 2, flw_breathless_pre___2 Short of breath when hurrying or when walking up a slight hill ; 3, flw_breathless_pre___3 Walks slower than most people of my age because of breathlessness, or have to stop for breath when walking at own pace ; 4, flw_breathless_pre___4 Stops for breath after walking 100 yards/ 90-100 metres, or after a few minutes on level ground ; 5, flw_breathless_pre___5 Too breathless to leave the house, or breathless when dressing/undressing
flw_fatigue text Please rate the intensity of your fatigue on average over the last 24 hours, on a scale from 0 - 10. Where: 0 = No fatigue 10 = Fatigue as bad as you can imagine (Type in the number recorded in the CRF, between 0 and 10)
flw_seeing_today The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM. radio Do you have difficulty seeing, even if wearing glasses? Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_seeing_pre_c19 radio Do you have difficulty seeing, even if wearing glasses? Before your Covid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_hearing_today radio Do you have difficulty hearing, even if using a hearing aid?Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_hearing_pre_c19 radio Do you have difficulty hearing, even if using a hearing aid?Before your Covid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_walking_today radio Do you have difficulty walking or climbing steps? Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_walking_pre_c19 radio Do you have difficulty walking or climbing steps? Before yourCovid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_remember_today radio Do you have difficulty remembering or concentrating? Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_remember_pre_c19 radio Do you have difficulty remembering or concentrating? Beforeyour Covid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_washing_today radio Do you have difficulty (with self-care such as) washing all overor dressing? Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_washing_pre_c19 radio Do you have difficulty (with self-care such as) washing all overor dressing? Before your Covid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_comm_today radio Using your usual (customary) language, do you have difficulty communicating, for example understanding or beingunderstood? Today 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_comm_pre_c19 radio Using your usual (customary) language, do you have difficulty communicating, for example understanding or beingunderstood? Before your Covid 19 illness 1, No - no difficulty ; 2, Yes - some difficulty ; 3, Yes - a lot of difficulty ; 4, Cannot do at all
flw_smoking Have you made lifestyle changes since your COVID-19 infection? radio Smoking 1, I do this more often ; 2, I do this less often ; 3, No difference ; 4, N/A
flw_alcohol radio Drinking alcohol 1, I do this more often ; 2, I do this less often ; 3, No difference ; 4, N/A
flw_healthy_eating radio Eating healthy food 1, I do this more often ; 2, I do this less often ; 3, No difference ; 4, N/A
flw_phys_activ radio Physical activity (including walking & cycling) 1, I do this more often ; 2, I do this less often ; 3, No difference ; 4, N/A
flw_walking_cycling radio Walking or cycling to work or school/college 1, I do this more often ; 2, I do this less often ; 3, No difference ; 4, N/A
flw_employ_pre_c19 A few questions about your employment status checkbox Before you got COVID-19 what was your employment status? 1, flw_employ_pre_c19___1 Full-time employment ; 2, flw_employ_pre_c19___2 Part time employment ; 3, flw_employ_pre_c19___3 Furloughed ; 4, flw_employ_pre_c19___4 Full time carer (children or other) ; 5, flw_employ_pre_c19___5 Unemployed ; 6, flw_employ_pre_c19___6 Unable to work due to chronic illness ; 7, flw_employ_pre_c19___7 Student ; 8, flw_employ_pre_c19___8 Retired ; 9, flw_employ_pre_c19___9 Medically retired ; 10, flw_employ_pre_c19___10 Prefer not to say
flw_employ_chg dropdown What is your employment status today? 1, Same as before ; 2, Different from before ; 3, Prefer not to say
flw_employ_today checkbox If different, please describe your employment status today? 1, flw_employ_today_c19___1 Full-time employment ; 2, flw_employ_today_c19___2 Part time employment ; 3, flw_employ_today_c19___3 Furloughed ; 4, flw_employ_today_c19___4 Full time carer (children or other) ; 5, flw_employ_today_c19___5 Unemployed ; 6, flw_employ_today_c19___6 Unable to work due to chronic illness ; 7, flw_employ_today_c19___7 Student ; 8, flw_employ_today_c19___8 Retired ; 9, flw_employ_today_c19___9 Medically retired ; 10, flw_employ_today_c19___10 todayfer not to say
flw_employ_chg_reason checkbox If different, why did you employment status change? 1, flw_employ_chg_reason___1 Poor health ; 2, flw_employ_chg_reason___2 New caring responsibility ; 3, flw_employ_chg_reason___3 Made redundant ; 4, flw_employ_chg_reason___4 Working hours reduced by employer ; 5, flw_employ_chg_reason___5 Other ; 6, flw_employ_chg_reason___6 Prefer not to say
flw_employ_chg_other text (If employment status has changed) specify other reason:
flw_sex_at_birth A few questions about yourself dropdown Sex at Birth: 1, Male ; 2, Female ; 3, Non-binary ; 4, Prefer not to say
flw_ethinicity checkbox Ethnicity (tick all that apply) 1, flw_ethinicity___1 White ; 2, flw_ethinicity___2 Arab ; 3, flw_ethinicity___3 Black ; 4, flw_ethinicity___4 East Asian ; 5, flw_ethinicity___5 South Asian ; 6, flw_ethinicity___6 West Asian ; 7, flw_ethinicity___7 Latin American ; 8, flw_ethinicity___8 Other ; 9, flw_ethinicity___9 Prefer not to say
flw_ethinicity_oth text Other ethnicity
flw_height text What is your estimated height:
flw_height_unit radio Height: Indicate unit measured in: 1, cm ; 2, feet ; 3, feet and inches ; 4, metres
flw_height_na radio What is your estimated height - prefer not to say 1, Prefer not to say
flw_weight text What is your current estimated weight:
flw_weight_unit radio Weight: Indicate unit measured in: 1, kg ; 2, lbs ; 3, stones and pounds
flw_weight_na radio What is your estimated weight - prefer not to say 1, Prefer not to say
flw_c19_e notes Please let us know if you feel COVID-19 has affected yourhealth or wellbeing in a way not described above?
follow_up_self_assessment_survey_complete Form Status dropdown Follow up Self Assessment Survey section complete? 0, Incomplete ; 1, Unverified ; 2, Complete