Submission Form

How would you rate the severity of your physical fatigue?

1 = No fatigue & seemingly healthy energy levels (able to work out or go for long walks etc).

10 = Any level of significant physical exertion (getting out of bed/taking a shower/...) is nearly impossible due to severe shortness of breath and/or extreme sleepiness.

0

1

2

3

4

5

6

7

8

9

10

How would you rate the severity of your brainfog?

1 = No brainfog & seemingly normal mental acuity.

10 = Simple mental tasks such as very basic maths or sending a short text message to a friend are very frequently not possible.

0

1

2

3

4

5

6

7

8

9

10

How would you rate the severity of your anhedonia?

1 = No anhedonia, regularly experiencing enjoyment, interest, etc.

10 = Most days and at almost all times completely unable to experience enjoyment or interest & incapable of finding the mental drive to start basic tasks eg. getting out of bed, taking a shower etc.

0

1

2

3

4

5

6

7

8

9

10

Are you pregnant or breast-feeding?

Do you have one of the following conditions: breast cancer, uterine cancer, ovarian cancer, endometriosis, or uterine fibroids?

Are you eighteen or older?

Email

If you have any questions, contact us at longcovidwatch@gmail.com