| ENTRY SPECIFICATION |
{"name": "C19-YRS",
<br />Rate the severity of each problem on a scale of 0-3:</i>
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q8985", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "1d. Breathlessness: On walking up a flight of stairs <i>[Now]</i>",
<br /> <hr />1. Breathlessness"
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
<br />Rate the severity of each problem on a scale of 0-3:</i>
<br /> <hr />1. Breathlessness",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8986", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "1d. Breathlessness: On walking up a flight of stairs <i>[Pre-COVID]</i>",
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
<br />Rate the severity of each problem on a scale of 0-3:</i>
{"id": "q8979", "type": "ChoiceQuestion", "required": false, "inline": false,
<br /> <hr />1. Breathlessness",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2500", "type": "IntroText",
"text": "1a. Breathlessness: At rest <i>[Now]</i>",
"text": "2. Cough / throat sensitivity / voice change"
},
{"id": "q8987", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "2a. Cough / throat sensitivity <i>[Now]</i>",
"intro": "2. Cough / throat sensitivity / voice change",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8988", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "2a. Cough / throat sensitivity <i>[Pre-COVID]</i>",
"intro": "2. Cough / throat sensitivity / voice change",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q8989", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "2b. Change of voice <i>[Now]</i>",
"intro": "2. Cough / throat sensitivity / voice change",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8990", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "2b. Change of voice <i>[Pre-COVID]</i>",
"intro": "2. Cough / throat sensitivity / voice change",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2501", "type": "IntroText",
"text": "3. Fatigue (tiredness not improved by rest)"
},
{"id": "q8991", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "3. Fatigue levels in your usual activities <i>[Now]</i>",
"intro": "3. Fatigue (tiredness not improved by rest)",
<br />Rate the severity of each problem on a scale of 0-3:</i>
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8992", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "3. Fatigue levels in your usual activities <i>[Pre-COVID]</i>",
"intro": "3. Fatigue (tiredness not improved by rest)",
"restartDays": 2,
<br /> <hr />1. Breathlessness",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2502", "type": "IntroText",
"text": "4. Smell / taste"
"columns": 1,
},
{"id": "q8993", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "4a. Altered smell <i>[Now]</i>",
"intro": "4. Smell / taste",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
"choices":[
]},
{"id": "q8994", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "4a. Altered smell <i>[Pre-COVID]</i>",
"intro": "4. Smell / taste",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q8995", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "4b. Altered taste <i>[Now]</i>",
"intro": "4. Smell / taste",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8996", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "4b. Altered taste <i>[Pre-COVID]</i>",
"intro": "4. Smell / taste",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2503", "type": "IntroText",
"text": "5. Pain / discomfort"
},
{"id": "q8997", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5a. Chest pain <i>[Now]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8998", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5a. Chest pain <i>[Pre-COVID]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
]},
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q8999", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5b. Joint pain <i>[Now]</i>",
"intro": "5. Pain / discomfort",
{"id": "q8980", "type": "ChoiceQuestion", "required": false, "inline": false,
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9000", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5b. Joint Pain <i>[Pre-COVID]</i>",
"intro": "5. Pain / discomfort",
"text": "1a. Breathlessness: At rest <i>[Pre-COVID]</i>",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9001", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5c. Muscle pain <i>[Now]</i>",
"printTitle": "Modified COVID-19 Yorkshire Rehabilitation Screening (C19-YRS)",
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9002", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5c. Muscle pain <i>[Pre-COVID]</i>",
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9003", "type": "ChoiceQuestion", "required": false, "inline": false,
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
"text": "5d. Headache <i>[Now]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9004", "type": "ChoiceQuestion", "required": false, "inline": false,
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
"text": "5d. Headache <i>[Pre-COVID]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
<br />Rate the severity of each problem on a scale of 0-3:</i>
{"id": "q9005", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5e. Abdominal pain <i>[Now]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
<br /> <hr />1. Breathlessness",
{"id": "q9006", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "5e. Abdominal pain <i>[Pre-COVID]</i>",
"intro": "5. Pain / discomfort",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
"columns": 1,
]},
{"id": "i2504", "type": "IntroText",
"text": "6. Cognition"
},
{"id": "q9007", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6a. Problems with concentration <i>[Now]</i>",
"intro": "6. Cognition",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
"choices":[
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9008", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6a. Problems with concentration <i>[Pre-COVID]</i>",
"intro": "6. Cognition",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9009", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6b. Problems with memory <i>[Now]</i>",
"intro": "6. Cognition",
"columns": 1,
"choices":[
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9010", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6b. Problems with memory <i>[Pre-COVID]</i>",
"intro": "6. Cognition",
"columns": 1,
"choices":[
"content":[
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9011", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6c. Problems with planning <i>[Now]</i>",
"intro": "6. Cognition",
"columns": 1,
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9012", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "6c. Problems with planning <i>[Pre-COVID]</i>",
"intro": "6. Cognition",
"columns": 1,
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2505", "type": "IntroText",
"text": "7. Palpitations / dizziness"
},
]},
{"id": "q9013", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "7a. Palpitations in certain positions, activity or at rest <i>[Now]</i>",
"intro": "7. Palpitations / dizziness",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8981", "type": "ChoiceQuestion", "required": false, "inline": false,
{"id": "q9014", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "7a. Palpitations in certain positions, activity or at rest <i>[Pre-COVID]</i>",
"intro": "7. Palpitations / dizziness",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
"text": "1b. Breathlessness: Changing position e.g. from lying to sitting or sitting to
]},
{"id": "q9015", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "7b. Dizziness in certain positions, activity or at rest <i>[Now]</i>",
"intro": "7. Palpitations / dizziness",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
lying <i>[Now]</i>",
]},
{"id": "q9016", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "7b. Dizziness in certain positions, activity or at rest <i>[Pre-COVID]</i>",
"intro": "7. Palpitations / dizziness",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2506", "type": "IntroText",
"text": "8. Post-exertional malaise (worsening of symptoms)"
},
{"id": "q9017", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "8. Crashing or relapse hours or days after physical, cognitive or emotional
exertion <i>[Now]</i>",
"intro": "8. Post-exertional malaise (worsening of symptoms)",
"columns": 1,
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9018", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "8. Crashing or relapse hours or days after physical, cognitive or emotional
exertion <i>[Pre-COVID]</i>",
"intro": "8. Post-exertional malaise (worsening of symptoms)",
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2507", "type": "IntroText",
"text": "9. Anxiety / mood"
{"id": "i2499", "type": "IntroText",
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
},
{"id": "q9019", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9a. Feeling anxious <i>[Now]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
<br />Rate the severity of each problem on a scale of 0-3:</i>
]},
{"id": "q9020", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9a. Feeling anxious <i>[Pre-COVID]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
<br /> <hr />1. Breathlessness",
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9021", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9b. Feeling depressed <i>[Now]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
"columns": 1,
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9022", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9b. Feeling depressed <i>[Pre-COVID]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
"choices":[
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9023", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9c. Having unwanted memories of your illness or time in hospital <i>[Now]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9024", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9c. Having unwanted memories of your illness or time in hospital <i>[Pre-COVID]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9025", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9d. Having unpleasant dreams about your illness or time in hospital <i>[Now]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9026", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9d. Having unpleasant dreams about your illness or time in hospital <i>[Pre-COVID]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9027", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9e. Trying to avoid thoughts or feelings about your illness or time in hospital
<i>[Now]</i>",
"intro": "9. Anxiety / mood",
"columns": 1,
]},
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9028", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "9e. Trying to avoid thoughts or feelings about your illness or time in hospital
<i>[Pre-COVID]</i>",
"intro": "9. Anxiety / mood",
"text": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
{"id": "q8982", "type": "ChoiceQuestion", "required": false, "inline": false,
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2508", "type": "IntroText",
"text": "10. Sleep"
"text": "1b. Breathlessness: Changing position e.g. from lying to sitting or sitting to
},
{"id": "q9029", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "10. Sleep problems, such as difficulty falling asleep, staying asleep or
oversleeping <i>[Now]</i>",
"intro": "10. Sleep",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
lying <i>[Pre-COVID]</i>",
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9030", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "10. Sleep problems, such as difficulty falling asleep, staying asleep or
oversleeping <i>[Pre-COVID]</i>",
"intro": "10. Sleep",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2509", "type": "IntroText",
"text": "<strong>FUNCTIONAL ABILITY</strong> <br /><br />11. Communication"
},
{"id": "q9031", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "11. Difficulty with communication / word finding difficulty / understanding
others <i>[Now]</i>",
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
"intro": "<strong>FUNCTIONAL ABILITY</strong> <br /><br />11. Communication",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9032", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "11. Difficulty with communication/word finding difficulty/understanding others
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
<i>[Pre-COVID]</i>",
"intro": "<strong>FUNCTIONAL ABILITY</strong> <br /><br />11. Communication",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
{"id": "i2510", "type": "IntroText",
"text": "12. Walking or moving around"
},
{"id": "q9033", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "12. Difficulties with walking or moving around <i>[Now]</i>",
"intro": "12. Walking or moving around",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
<br />Rate the severity of each problem on a scale of 0-3:</i>
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9034", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "12. Difficulties with walking or moving around <i>[Pre-COVID]</i>",
"intro": "12. Walking or moving around",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
<br /> <hr />1. Breathlessness",
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2511", "type": "IntroText",
"text": "13. Personal Care"
},
{"id": "q9035", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "13. Difficulties with personal tasks such as using the toilet or getting washed
and dressed <i>[Now]</i>",
"columns": 1,
"intro": "13. Personal Care",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9036", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "13. Difficulties with personal tasks such as using the toilet or getting washed
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
"choices":[
and dressed <i>[Pre-COVID]</i>",
"intro": "13. Personal Care",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "i2512", "type": "IntroText",
"text": "14. Other activities of Daily Living"
},
{"id": "q9037", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "14. Difficulty doing wider activities, such as household work, leisure/sporting
activities, paid/unpaid work, study or shopping <i>[Now]</i>",
"intro": "14. Other activities of Daily Living",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q9038", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "14. Difficulty doing wider activities, such as household work, leisure/sporting
activities, paid/unpaid work, study or shopping <i>[Pre-COVID]</i>",
"intro": "14. Other activities of Daily Living",
"columns": 1,
"choices":[
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2513", "type": "IntroText",
"text": "15. Social role"
},
{"id": "q9039", "type": "ChoiceQuestion", "required": false, "inline": false,
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
"text": "15. Problems with socializing / interacting with friends* or caring for
dependants <i>[Now]</i><br />* related to your illness and not due to social distancing /
lockdown measures",
"intro": "15. Social role",
"columns": 1,
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "q9040", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "15. Problems with socializing / interacting with friends* or caring for
dependants <i>[Pre-COVID]</i><br />* related to your illness and not due to social distancing /
lockdown measures",
"intro": "15. Social role",
"columns": 1,
"choices":[
{"id": "c5544", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5545", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
]},
{"id": "c5546", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
{"id": "c5547", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3},
{"id": "c5548", "text": "4. Don't know", "quickKey": 4}
]},
{"id": "i2514", "type": "IntroText",
"text": "<strong>OTHER SYMPTOMS</strong>"
},
{"id": "q9041", "type": "CheckQuestion", "required": false, "inline": false,
"text": "16a. Please select any of the following symptoms you have experienced since your
illness in the last 7 days. Please also select any previous problems that have
{"id": "q8983", "type": "ChoiceQuestion", "required": false, "inline": false,
worsened for you following your illness.",
"intro": "<strong>OTHER SYMPTOMS</strong>",
"columns": 1,
"choices":[
{"id": "c5549", "text": " Fever"},
{"id": "c5550", "text": " Skin rash / discoloration of skin"},
{"id": "c5551", "text": " New allergy such as medication, food etc."},
{"id": "c5552", "text": " Hair loss"},
{"id": "c5553", "text": " Skin sensation (numbness / tingling / itching / nerve pain)"},
{"id": "c5554", "text": " Dry eyes / redness of eyes"},
"text": "1c. Breathlessness: On dressing yourself <i>[Now]</i>",
{"id": "c5555", "text": " Swelling of feet / swelling of hands"},
{"id": "c5556", "text": " Easy bruising / bleeding"},
{"id": "c5557", "text": " Visual changes"},
{"id": "c5558", "text": " Difficulty swallowing solids"},
{"id": "c5559", "text": " Difficulty swallowing liquids"},
{"id": "c5560", "text": " Balance problems or falls"},
{"id": "c5561", "text": " Weakness or movement problems or coordination problems in limbs"},
{"id": "c5562", "text": " Tinnitus"},
{"id": "c5563", "text": " Nausea"},
{"id": "c5564", "text": " Dry mouth / mouth ulcers"},
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
{"id": "c5565", "text": " Acid Reflux / heartburn"},
{"id": "c5566", "text": " Change in appetite"},
{"id": "c5567", "text": " Unintentional weight loss"},
{"id": "c5568", "text": " Unintentional weight gain"},
{"id": "c5569", "text": " Bladder frequency, urgency or incontinence"},
{"id": "c5570", "text": " Constipation, diarrhea or bowel incontinence"},
{"id": "c5571", "text": " Change in menstrual cycles or flow"},
{"id": "c5572", "text": " Waking up at night gasping for air (also called sleep apnea)"},
{"id": "c5573", "text": " Thoughts about harming yourself"}
]},
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
{"id": "q9042", "type": "MemoQuestion", "required": false,
"text": "16b. Other symptoms - free text",
"intro": "<strong>OTHER SYMPTOMS</strong>",
"controlWidth": 662},
{"id": "i2515", "type": "IntroText",
"text": "<strong>OVERALL HEALTH</strong> <br /><br />For this question, a score of 10 means the BEST health
you can imagine. 0 means the WORST health you can imagine."
},
{"id": "q9043", "type": "SliderQuestion", "required": false,
"text": "17a. How good or bad is your health overall in the last 7 days? <i>[Now]</i>",
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
"intro": "<strong>OVERALL HEALTH</strong> <br /><br />For this question, a score of 10 means the BEST health
you can imagine. 0 means the WORST health you can imagine.",
"min": 0, "max": 10,
"legend":["WORST HEALTH", "BEST HEALTH"]},
{"id": "q9044", "type": "SliderQuestion", "required": false,
"text": "17b. How good or bad is your health overall in the last 7 days? <i>[Pre-COVID]</i>",
"intro": "<strong>OVERALL HEALTH</strong> <br /><br />For this question, a score of 10 means the BEST health
you can imagine. 0 means the WORST health you can imagine.",
"min": 0, "max": 10,
"legend":["WORST HEALTH", "BEST HEALTH"]},
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
{"id": "i2516", "type": "IntroText",
"text": "<strong>EMPLOYMENT</strong>"
},
{"id": "q9045", "type": "StringQuestion", "required": false,
"text": "18a. Occupation",
"intro": "<strong>EMPLOYMENT</strong>",
"controlWidth": 662, "min": 0, "max": 0},
{"id": "q9046", "type": "CheckQuestion", "required": false, "inline": false,
"text": "18b. Has your COVID-19 illness affected your work?",
"intro": "<strong>EMPLOYMENT</strong>",
<br />Rate the severity of each problem on a scale of 0-3:</i>
"columns": 1,
"choices":[
{"id": "c5576", "text": " No change"},
{"id": "c5577", "text": " On reduced working hours"},
{"id": "c5578", "text": " On sickness leave"},
{"id": "c5579", "text": " Changes made to role / working arrangements (such as working from home or lighter
duties)"},
{"id": "c5580", "text": " Had to retire / change job"},
{"id": "c5581", "text": " Lost job"}
]},
<br /> <hr />1. Breathlessness",
{"id": "q9047", "type": "MemoQuestion", "required": false,
"text": "18c. Any other comments/concerns",
"intro": "<strong>EMPLOYMENT</strong>",
"controlWidth": 662},
{"id": "i2517", "type": "IntroText",
"text": "<strong>PARTNER / FAMILY / CAREGIVER PERSPECTIVE</strong>"
},
{"id": "q9048", "type": "MemoQuestion", "required": false,
"text": "19. This is space for your partner, family or caregiver to add anything from their
perspective",
"columns": 1,
"intro": "<strong>PARTNER / FAMILY / CAREGIVER PERSPECTIVE</strong>",
"controlWidth": 662}]
}
"choices":[
{"id": "c5540", "text": "0. None; no problem", "quickKey": 0},
{"id": "c5541", "text": "1. Mild problem; does not affect daily life", "quickKey": 1},
{"id": "c5542", "text": "2. Moderate problem; affects daily life to a certain extent", "quickKey": 2},
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
{"id": "c5543", "text": "3. Severe problem; affects all aspects of daily life; life-disturbing", "quickKey": 3}
]},
{"id": "q8984", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "1c. Breathlessness: On dressing yourself <i>[Pre-COVID]</i>",
"intro": "<strong>SYMPTOM SEVERITY</strong> <br /> <br /><i>Please answer the questions below to the best of
your knowledge. <br /><strong>[Now]</strong> refers to how you feel now/this week (last 7 days).
<br /><strong>[Pre-COVID]</strong> refers to how you were feeling prior to contracting the
illness. <br />If you are unable to recall this, just select </i>\u0022Don't know\u0022<i>. <br />
<br />Rate the severity of each problem on a scale of 0-3:</i>
<br /> <hr />1. Breathlessness",
|
