Protocol - Long COVID - Physical Functioning

1. Before COVID-19, were you limited in any way in any activities because of physical, mental, or emotional problems?

[ ] Yes (specify)

[ ] No

[ ] Refuse to answer

 1a. Please specify how you were limited before COVID-19: ___________

2. Before COVID-19, did you have any health problem that required you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

*Include occasional use or use in certain circumstances

[ ] Yes

[ ] No

[ ] Refuse to answer

3. Do you have any difficulty walking a quarter of a mile, that is about 2 or 3 blocks, without stopping?

[ ] Yes

[ ] No

[ ] Refuse to answer

4. How much difficulty do you have walking a quarter of a mile?

[ ] A little

[ ] Some

[ ] A lot

[ ] Unable to do

[ ] Refuse to answer

5. Did you have difficulty walking a quarter of a mile before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

6. How easy is it for you to walk a quarter of a mile?

[ ] Very easy

[ ] Somewhat easy

[ ] Not so easy

[ ] Refuse to answer

7. Do you have any difficulty walking a distance of one mile?

[ ] Yes

[ ] No

[ ] Refuse to answer

8. Did you have difficulty walking one mile before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

9. How easy is it for you to walk one mile?

[ ] Very easy

[ ] Somewhat easy

[ ] Not so easy

[ ] Refuse to answer

10. Do you have any difficulty walking up 10 steps, that is about 1 flight, without resting?

[ ] Yes

[ ] No

[ ] Refuse to answer

11. How much difficulty do you have walking up 10 steps?

[ ] A little

[ ] Some

[ ] A lot

[ ] Unable to do

[ ] Refuse to answer

12. Did you have difficulty walking up 10 steps before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

13. How easy is it for you to walk up 10 steps?

[ ] Very easy

[ ] Somewhat easy

[ ] Not so easy

[ ] Refuse to answer

14. Do you have any difficulty walking up 20 steps, that is about 2 flights, without resting?

[ ] Yes

[ ] No

[ ] Refuse to answer

15. Did you have difficulty walking up 20 steps before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

16. How easy is it for you to walk up 20 steps?

[ ] Very easy

[ ] Somewhat easy

[ ] Not so easy

[ ] Refuse to answer

17. Do you have difficulty doing light housework such as doing dishes, straightening up or light cleaning by yourself?

[ ] Yes

[ ] No

[ ] Refuse to answer

18. How much difficulty do you have doing light housework?

[ ] A little

[ ] Some

[ ] A lot

[ ] Unable to do

[ ] Refuse to answer

19. Did you have difficulty doing light housework before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

20. Do you have difficulty doing heavy housework such as vacuuming and washing windows, walls, or floors?

[ ] Yes

[ ] No

[ ] Refuse to answer

21. How much difficulty do you have doing heavy housework?

[ ] A little

[ ] Some

[ ] A lot

[ ] Unable to do

[ ] Refuse to answer

22. Did you have difficulty doing heavy housework before your COVID-19 illness?

[ ] Yes

[ ] No

[ ] Refuse to answer

23. Prior to your initial COVID-19 illness, during a typical 7-day period (a week), how many times on average did you do the following kinds of exercise for more than 15 minutes during your free time?

 23a. Strenuous exercise (heart beats rapidly)?

 __________times per week

 Examples: running, jogging, hockey, football, soccer, squash, basketball,

 cross country skiing, judo, roller skating, vigorous swimming, vigorous long

 distance bicycling

 23b. Moderate exercise (not exhausting)?

 __________times per week

 Examples: fast walking, baseball, tennis, easy bicycling, volleyball,

 badminton, easy swimming, alpine skiing, popular and folk dancing

 23c. Mild/light exercise (minimal effort)?

 __________times per week

 Examples: yoga, archery, fishing from river bank, bowling, horseshoes, golf,

 snow-mobiling, easy walking

24. Since your initial COVID-19 illness, during a typical 7-day period (a week), how many times on average do you do the following kinds of exercise for more than 15 minutes during your free time?

 24a. Strenuous exercise (heart beats rapidly)?

 __________times per week

 Examples: running, jogging, hockey, football, soccer, squash, basketball,

 cross country skiing, judo, roller skating, vigorous swimming, vigorous long

 distance bicycling

 24b. Moderate exercise (not exhausting)?

 __________times per week

 Examples: fast walking, baseball, tennis, easy bicycling, volleyball,

 badminton, easy swimming, alpine skiing, popular and folk dancing

 24c. Mild/light exercise (minimal effort)?

 __________times per week

 Examples: yoga, archery, fishing from river bank, bowling, horseshoes, golf,

 snow-mobiling, easy walking