Protocol - COVID-19 Related Health Questions

1. We are interested in whether you have experienced any symptoms listed below since November 2019. Please complete the table for any of the symptoms you have had and in what month(s) you had them. Please complete for any symptoms and any months that symptoms were experienced irrespective of whether or not you saw a doctor and irrespective of whether or not you were told you had flu, or coronavirus disease 2019 (COVID-19) or any other diagnosis

2. If you have had any of the symptoms above in the last week:

   2a. when did the first one start?

      [ ] 1 day ago

      [ ] 2 days ago

      [ ] 3 days ago

      [ ] 4 days ago

      [ ] 5 days ago

      [ ] 6 days ago

      [ ] 7 days ago

      [ ] Can’t remember

   2b. when did the last one finish?

      [ ] 1 day ago

      [ ] 2 days ago

      [ ] 3 days ago

      [ ] 4 days ago

      [ ] 5 days ago

      [ ] 6 days ago

      [ ] 7 days ago

      [ ] Can’t remember

      [ ] I still have it/them

   2c. In the last week have you had shortness of breath (difficulty breathing)?

      [ ] No

      [ ] Yes, but did not affect my normal activities

      [ ] Yes, did affect my normal activities (e.g. walking short distances)

      [ ] Yes, even when I was sat or lying down

   2d. Did you seek medical attention for the symptoms you had in the last week?

      [ ] Yes

      [ ] No

   If 2d = No, skip to question 3

   2e. If yes, what kind of medical attention did you access? [tick all that apply]

      [ ] Contacted NHS 111, by phone or online

      [ ] Visited pharmacist

      [ ] Consulted GP/practice nurse over the phone or online

      [ ] Consulted GP/practice nurse face to face

      [ ] Walk-in centre

      [ ] Accident and Emergency

      [ ] Other, please specify _______

3.

   3a. In the last week have you had your temperature taken?

      [ ] Yes

      [ ] No

   If 3a = No, skip to question 4

   3b. Who took your temperature?

      [ ] A doctor/nurse or other health professional

      [ ] I did

      [ ] It was taken by someone else

   3c. If you can remember, what was the highest temperature reading?

   _ _ . _ C

4. Have you been in close contact with anyone with COVID-19 in the last two weeks?

[ ] Yes, I was in contact with a confirmed/tested COVID-19 case

[ ] Yes, I was in contact with a suspected COVID-19 case

[ ] No, not to my knowledge

5.

   5a. Do you think that you have or have had COVID-19?

[ ] Yes, confirmed by a positive test

[ ] Yes, suspected by a doctor but not tested

[ ] Yes, my own suspicions

[ ] No

   If 5a = No, go to question 6

   5b. If yes, when were you told/when did you think you first had COVID-19?

   _ _ / _ _ / _ _ _ _ (DD/MM/YY)

6.

   6a. Are you, or do you, currently have any of the following? (tick all that apply)

   6b. If yes, please tell us exactly what you have:

   ___________________

   6c. Have you been contacted by letter or text message to say you are at severe risk from COVID-19 due to an underlying health condition and should be shielding (avoiding exposure)?

1[ ]Yes

2[ ]No

7. For each of the following questions please respond Yes or No

8. Do you currently take any regular medication?

[ ] Yes

[ ] No

9. Have you had a flu jab (flu shot) in the last 12 months?

[ ] Yes

[ ] No