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

Headaches

1. Have you experienced any new HEADACHES OR RELATED ISSUES since the start of your COVID-19 illness?

[ ] Yes

[ ] No

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

[ ] Headaches, at the base of the skull

[ ] Headaches, in the temples

[ ] Headaches, behind the eyes

[ ] Headaches, diffuse (entire brain)

[ ] Headaches/pain after mental exertion

[ ] Headaches, other: ______________

[ ] Sensation of brain warmth/"on fire"

[ ] Sensation of brain pressure

[ ] Migraines

[ ] Stiff neck

[ ] None of the above

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.

Sense of Smell and Taste

4. Have you experienced any changes to your SENSE OF SMELL OR TASTE since the start of your COVID-19 illness?

[ ] Yes

[ ] No

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

[ ] Loss of smell

[ ] Phantom smells (imagining/hallucinating smells - smelling things that arent there)

[ ] Heightened sense of smell

[ ] Altered sense of smell

[ ] Loss of taste

[ ] Phantom taste (imagining/hallucinating tastes - tasting things when theres nothing in your mouth)

[ ] Heightened sense of taste

[ ] Altered sense of taste

[ ] None of the above

6. 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.

7. If you had phantom tastes, please describe them:

________________________________________________

8. If you had phantom smells, please describe them:

________________________________________________

Tremors and Vibrating Sensations

9. Have you experienced any TREMOR OR VIBRATION SENTATIONS since the start of your COVID-19 illness?

Tremor: Involuntary, rhythmic muscle contraction leading to shaking movements in one or more parts of the body

Vibration sensation: A buzzing feeling, when you feel like your muscles, fingers, or legs are vibrating or shaking inside, but you dont see the movement

[ ] Yes

[ ] No

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

Please specify the location on your body in the text box. If multiple locations, please separate them with a comma (i.e. leg, torso, hand).

[ ] Tremors: ________________

[ ] Vibrating sensations: ________________

11. 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.

12. Please use this space to describe examples of your tremors or body vibration/shaking during your illness.

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

________________________________________________

Weakness, numbness, tingling, coldness, and other sensations

13. Which of the following NEUROLOGICAL SENSATION SYMPTOMS have you experienced since the start of your COVID-19 illness, if any?

Please specify the location on your body in the text box. If multiple locations, please separate them with a comma (i.e. hand, leg, foot).

[ ] Skin sensations: burning, tingling, or itchiness without rash

[ ] Numbness/loss of sensation: ________________

[ ] Numbness/weakness on one side of the body only

[ ] Coldness: ________________

[ ] Tingling/prickling/pins and needles sensation: ________________

[ ] Electrical zaps/electrical shock sensation: ________________

[ ] Facial paralysis (please indicate where on face was paralyzed): ________________

[ ] Sensation of facial pressure/numbness, left side

[ ] Sensation of facial pressure/numbness, right side

[ ] Sensation of facial pressure/numbness, other: ________________

[ ] Weakness: ________________

[ ] None of the above

14. 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.