Protocol - Long COVID - Symptoms Due to COVID-19 - Memory

Memory Symptoms

1. Have you experienced any MEMORY RELATED SYMPTOMS since the start of your COVID-19 illness?

[ ] Yes

[ ] No

2. Which of the following memory symptoms have you experienced since the start of your COVID-19 illness?

[ ] Short-term memory loss (memory that lasts ~30 seconds, i.e. remembering a phone number before writing it down, or forgetting youre in the middle of a task)

[ ] Long-term memory loss (long-term memory can be anything from remembering yesterday, forgetting youve done a task, forgetting recently learned information, or forgetting your third-grade experience)

[ ] Not being able to make new memories

[ ] Forgetting how to do routine tasks (tying your shoe laces, washing your hands)

[ ] None of the above

[ ] Other __________

3. When did you experience these symptoms?

Please mark symptoms for the first 4 weeks, then months (if applicable). Even if you have only experienced these symptoms for part of a week or month, please select it.

Cognitive Function/Brain Fog Symptoms

4. Have you experienced issues with BRAIN FOG (inability to focus, think clearly, plan, process, understand, and maintain a coherent stream of thought; abnormally slow or fast thoughts) since the start of your COVID-19 illness?

[ ] Yes

[ ] No

5. Which of the following brain fog/cognitive functioning symptoms have you experienced since the start of your COVID-19 illness?

[ ] Difficulty with executive functioning (planning, organizing, figuring out the sequence of actions, abstracting)

[ ] Agnosia (failure to recognize or identify objects despite intact sensory functioning)

[ ] Difficulty problem-solving or decision-making

[ ] Difficulty thinking

[ ] Thoughts moving too quickly

[ ] Slowed thoughts

[ ] Poor attention or concentration

[ ] I did NOT have any Brain Fog symptoms

[ ] Other

6. When did you experience these symptoms?

Please mark symptoms for the first 4 weeks, then months (if you havent yet reached a week/month, please leave it blank). Even if you have only experienced these symptoms for part of a week or month, please select it.

Changes to Daily/Functional Abilities due to memory loss or brain fog

7. Have you felt significantly limited or unable to do any of the following due to MEMORY LOSS OR BRAIN FOG (including issues with attention, cognitive functioning, and awareness) specifically?

8. Optional: If you have other areas of your life that were affected by memory loss or brain fog, please include them here. Please note whether they were mildly, moderately, or severely limiting.

______________________________________

9. Optional: Please use this space to describe examples of your brain fog, memory loss, and attention span.

Please do not include any identifying information (such as name or location).

______________________________________