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 |