COVID-19 Yorkshire Rehabilitation Screening (C19-YRS) - Modified

The purpose of this questionnaire is to find out more about your current problems following COVID19 illness. Your responses will be recorded in your clinical notes. We will use this information to monitor your symptoms, offer treatments and assess your response to treatment. This questionnaire will take around 10 minutes. If there are any topics you don’t want to talk about, you can choose not to respond.

First Name *

Last Name *

DOB: *

EmailEnter your email if you would also like to receive a copy of the completed form.

Key Symptoms

The column below is for symptoms you experience NOW.

The column below is for symptoms you experienced BEFORE COVID.

1. Breathlessness (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

At rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Changing position e.g. from lying to sitting or sitting to lying

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

On dressing yourself

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

On walking up a flight of stairs

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

1. Breathless (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

At rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Changing position e.g. from lying to sitting or sitting to lying

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

On dressing yourself

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

On walking up a flight of stairs

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

2. Cough/ throat sensitivity/ voice change (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Cough/ throat sensitivity

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Change of voice

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

2. Cough/ throat sensitivity/ voice change (BEFORE COVID)) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Cough/ throat sensitivity

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Change of voice

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

3. Fatigue (tiredness not improved by rest) (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Fatigue levels in your usual activities

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

3. Fatigue (tiredness not improved by rest) (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Fatigue levels in your usual activities

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

4. Smell/taste (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Altered smell

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Altered taste

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

4. Smell/taste (BEFORE COVID)) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Altered smell

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Altered taste

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

5. Pain/discomfort (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Chest pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Joint pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Muscle pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Headache

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Abdominal pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

5. Pain/discomfort (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Chest pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Joint pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Muscle pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Headache

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Abdominal pain

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

6. Cognition (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with concentration

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with memory

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with planning

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

6. Cognition (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with concentration

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with memory

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with planning

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

7. Palpitations/ dizziness (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Palpitations in certain positions, activity or at rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Dizziness in certain positions, activity or at rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

7. Palpitations/ dizziness (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Palpitations in certain positions, activity or at rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Dizziness in certain positions, activity or at rest

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

8. Post-exertional malaise (worsening of symptoms) (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Crashing or relapse hours or days after physical, cognitive or emotional exertion

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

8. Post-exertional malaise (worsening of symptoms) (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Crashing or relapse hours or days after physical, cognitive or emotional exertion

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

9. Anxiety/ mood (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Feeling anxious

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Feeling depressed

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Having unwanted memories of your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Having unpleasant dreams about your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Trying to avoid thoughts or feelings about your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

9. Anxiety/ mood (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Feeling anxious

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Feeling depressed

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Having unwanted memories of your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Having unpleasant dreams about your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Trying to avoid thoughts or feelings about your illness or time in the hospital

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

---

10. Sleep (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Sleep problems, such as difficulty falling asleep, staying asleep or oversleeping

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

10. Sleep (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Sleep problems, such as difficulty falling asleep, staying asleep or oversleeping

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

FUNCTIONAL ABILITY

11. Communication (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulty with communication, word finding difficulty or understanding others

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

11 Communication (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulty with communication, word finding difficulty or understanding others

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

12. Walking or moving around (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulties with walking or moving around

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

12. Walking or moving around (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulties with walking or moving around

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

13. Personal care (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulties with personal tasks such as using the toilet or getting washed and dressed

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

13. Personal care (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulties with personal tasks such as using the toilet or getting washed and dressed

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

14. Other activities of Daily Living (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

14. Other activities of Daily Living (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Difficulty doing wider activities, such as household work, leisure/sporting activities, paid/unpaid work, study or shopping

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

15. Social role (NOW) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with socialising/interacting with friends* or caring for dependants

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

* related to your illness and not due to social distancing/lockdown measures

15. Social role (BEFORE COVID) *

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

Problems with socialising/interacting with friends* or caring for dependants

None; no problemMild problem; does not affect daily lifeModerate problem; affects daily life to a certain extentSevere problem; affects all aspects of daily life; life-disturbing

* related to your illness and not due to social distancing/lockdown measures

OTHER SYMPTOMS

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 worsened for you following your illness.

FeverSkin rash/ discolouration of skinNew allergy such as medication, food etcHair lossSkin sensation (numbness/tingling/itching/nerve pain)Dry eyes/ redness of eyesSwelling of feet/ swelling of handsEasy bruising/ bleedingVisual changesDifficulty swallowing solidsDifficulty swallowing liquidsBalance problems or fallsWeakness or movement problems or coordination problems in limbsTinnitusNauseaDry mouth/mouth ulcersAcid Reflux/heartburnChange in appetiteUnintentional weight lossUnintentional weight gainBladder frequency,urgency or incontinence 3 4Constipation, diarrhoea or bowel incontinenceChange in menstrual cycles or flowWaking up at night gasping for air (also called sleep apnea)Thoughts about harming yourself

Other symptomsPlease type in other symptoms you have experienced.

Overall health

Overall Health (NOW)

0 (Worst Health)12345678910 (Best Health)

How good or bad is your health overall in the last 7 days?

0 (Worst Health)12345678910 (Best Health)

For this question, a score of 10 means the BEST health you can imagine. 0 means the WORST health you can imagine.

Overall Health (BEFORE COVID)

0 (Worst Health)12345678910 (Best Health)

How good or bad is your health overall in the last 7 days?

0 (Worst Health)12345678910 (Best Health)

For this question, a score of 10 means the BEST health you can imagine. 0 means the WORST health you can imagine.

Employment

Your occupationIf retired, then please type retired.

Has your COVID-19 illness affected your work? *

No changeOn reduced working hoursOn sickness leaveChanges made to role/ working arrangements (such as working from home or lighter duties)Had to retire/ change jobLost jobNot relevant

Any other comments/concerns

PARTNER or FAMILY or CARER PERSPECTIVE

PARTNER/FAMILY/CARER PERSPECTIVEThis is space for your partner, family or carer to add anything from their perspective.

---

Total score for key symptoms

Total Symptom Score (NOW)

Total Symptom Score (BEFORE COVID)

Total score for function

Total Function Score (NOW)

Total Function Score (BEFORE COVID)

Thank you for completing this patient-reported measure for COVID-19. Your results have been sent to Next Practice Deakin.

Reference:

https://c19-yrs.com/the-c19-yrs/

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