COVID-19 Yorkshire Rehabilitation Screening Tool

Following on are some questions about how you might have been affected since your illness.

If there are other ways that you've been affected, then there will be a chance to describe these at the end.

Last Updated: 26/11/2024

Breathlessness

At rest, - Now: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you:

At Rest - Pre Covid: On a scale of 0-10 with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you:

On dressing yourself - now: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity)

n/a

On dressing yourself - pre-covid: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (N/A if does not perform this activity)

n/a

On walking up a flight of stairs - now: on a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity)

n/a

On walking up a flight of stairs - pre-covid: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity)

n/a

Laryngeal/Airway Complications

Have you developed any changes in the sensitivity of your throat such as troublesome cough or noisy breathing?

Yes

If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact)

Voice

Have you or your family noticed any changes to your voice such as difficulty being heard, altered quality of the voice, your voice tiring by the end of the day or an inability to alter the pitch of your voice?

Yes

If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact)

Swallowing

Are you having difficulties eating, drinking or swallowing such as coughing , choking or avoiding any food or drinks?

Yes

If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact)

Nutrition

Are you or your family concerned that you have ongoing weight loss or any ongoing nutritional concerns as a result of COVID-19?

Yes

Please rank your appetite or interest in eating on a scale of 0-10 since COVID-19 (0 being the same as usual/no problems, 10 being very severe problems/reduction)

Mobility

On a 0-10 scale, how severe are any problems you have in walking about? - Now (0 means I have no problems, 10 means I am completely unable to walk)

On a 0-10 scale, how severe are any problems you have in walking about? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to walk)

Fatigue

Do you become fatigued more easily compared to before your illness?

Yes

If yes, how severely does this affect your mobility, personal cares, activities or enjoyment of life? - Now (0 being not affecting, 10 being very severely impacting)

If yes, how severely does this affect your mobility, personal cares, activities or enjoyment of life? - Pre-Covid (0 being not affecting, 10 being very severely impacting)

Personal Care

On a 0-10 scale, how severe are any problems you have in personal cares such as washing and dressing yourself? - Now (0 means I have no problems, 10 means I am completely unable to do my personal care)

On a 0-10 scale, how severe are any problems you have in personal cares such as washing and dressing yourself? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to do my personal care)

Continence

Since your illness are you having any new problems with: Controlling your bowel?

Yes

Since your illness are you having any new problems with: controlling your bladder?

Yes

Usual Activities

On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as your household leisure activities, work or study? - Now (0 means I have no problems, 10 means I am completely unable to do my usual activities)

On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as your household leisure activities, work or study? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to do my usual activities)

Pain/Discomfort

On a 0-10 scale, how severe is any pain or discomfort you have? - Now (0 means I have no pain or discomfort, 10 means I have extremely severe pain)

On a 0-10 scale, how severe is any pain or discomfort you have? - Pre COVID (0 means I have no pain or discomfort, 10 means I have extremely severe pain)

Cognition

Since your illness have you had new or worsened difficulty with: Concentrating?

Yes

Since your illness have you had new or worsened difficulty with: Short term memory?

Yes

Cognitive-Communication

Have you or your family noticed any change in the way you communicate with people, such as making sense of things people say to you, putting thoughts into words, difficulty reading or having a conversation?

Yes

If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact)

Anxiety

On a 0-10 scale, how severe is the anxiety you are experiencing? - Now (0 means I am not anxious, 10 means I have extreme anxious)

On a 0-10 scale, how severe is the anxiety you are experiencing? - Pre COVID (0 means I am not anxious, 10 means I have extreme anxious)

Depression

On a 0-10 scale, how severe is the depression you are experiencing? - Now (0 means I am not depressed, 10 means I have extreme depression)

On a 0-10 scale, how severe is the depression you are experiencing? - Pre COVID (0 means I am not depressed, 10 means I have extreme depression)

Global Perceived Health

How good or bad is your health overall? - Now (0 means the worst health you can imagine, 10 means the best health you can imagine)

How good or bad is your health overall? - Pre COVID (0 means the worst health you can imagine, 10 means the best health you can imagine)

Vocation

What is your employment situation and has your illness affected your ability to do your usual work?

What is your occupation?

Employment status before COVID-19 lockdown:

Employment status before you became ill:

Employment status now:

Family/carers views

Do you think your family or carer would have anything to add from their perspective?

Yes

Closing questions:

Are you experiencing any other new problems since your illness that haven't been mentioned above?

Yes

Would you be prepared to be contacted for future research?

Yes

Further comments:

Oops... There was an error contacting reCAPTCHA, Please try again.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Ravenswood Medical Practice website

COVID-19 Yorkshire Rehabilitation Screening Tool

Further Information