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DePaul Symptom Questionnaire-COVID

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DePaul Symptom Questionnaire-COVID
1. With which COVID variant were you infected? (Circle all that apply)
a. Alpha
b. Beta
c. Gamma
d. Delta
e. Omicron
f. Other (Please specify) _____________________________
g. Don’t know
2. How were you diagnosed with COVID? (Circle all that apply)
a. Positive PCR test
b. Positive antigen result (rapid test)
c. Positive antibody result (blood test)
d. Positive result, but not sure which test
e. Diagnosed by a doctor based on symptoms
f. Self-diagnosed by symptoms
3. Have you been hospitalized for COVID?
a. No
b. Yes (How many days?) ______________
4. While in the hospital, were you intubated for COVID?
a. No
b. Yes (How many days?) ______________
5. Have you been vaccinated for COVID? (Circle one response)
a. No
b. One shot, please specify what type of vaccine ______________
c. Two shots, please specify what types of vaccine _____________
6. Have you had any COVID booster shots? (Circle one response)
a. No
b. Yes, specify number and type _______________
7. When did you begin having symptoms for COVID? (mm/dd/yyyy) __________
8. Has there been documented damage done to one or more organ areas due to the COVID
infection? (For example, respiratory, nervous system, metabolic, cardiovascular, stroke,
gastrointestinal, arthritis, skin disorders, pulmonary embolism)
a. No
b. Yes (Please specify) ________________________________________________
9. List any medical problems you had prior to being infected with COVID.
________________________________________________________________________
10. Which statement best describes your fatigue/energy level over the last month? (Circle
one response)
a. I am not able to work or do anything, and I am bedridden.
b. I can walk around the house, but I cannot do light housework.
c. I can do light housework, but I cannot work part-time.
d. I can only work part-time at work or on some family responsibilities.
e. I can work full time, but I have no energy left for anything else.
f. I can work full time and finish some family responsibilities, but I have no energy left
for anything else.
g. I can do all work or family responsibilities without any problems with my energy.
11. Since the onset of your problems with fatigue/energy, have your symptoms caused a 50% or
greater reduction in your activity level? (Circle one response)
a. No
b. Yes
c. Not having a problem with fatigue/energy
For each symptom below, please circle one number for frequency and one number for severity.
Please complete the chart from left to right.
Frequency:
past monthhow oen


0 = none of the me
1 = a lile of the me
2 = about half the me
3 = most of the me
4 = all of the me
Severity:
past month
how severe

0 = symptom not present
1 = mild
2 = moderate
3 = severe
4 = very severe
Symptom Frequency: Severity:
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885
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$#<72  "#$ "#$
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50. If you have or have had other symptoms, please list them below:_____________________
_____________________________________________________________________________
51. Do you have what has been referred to as chronic fatigue syndrome, Myalgic Encephalomyelitis, or
Myalgic Encephalomyelitis/chronic fatigue syndrome? (Circle one response below)
a. No
b. Yes, already had this condition before I had COVID-19
c. Yes, I have this condition after I had COVID-19
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