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Date of this Experience log
*
What ARE you currently experiencing that you think is related to your getting COVID-19
*
Tiredness
fatigue
Difficulty thinking
Difficulty concentrating (sometimes called “brain fog”)
Shortness of breath
difficulty breathing
Headache
Dizziness
Dizziness on standing
Fast-beating
pounding heart (known as heart palpitations)
Chest pain
Cough
Joint pain
muscle pain
Depression
anxiety
Fever
Loss of taste
Loss of smell
heart
lungs
kidneys
skin
brain
Lung damage
Heart damage, (including inflammation of the heart muscle)
Kidney damage
Neurological damage
Damage to the circulatory system resulting in poor blood flow
Other
Other
PLease Check all that apply
What were you concerned about during your infection?
*
Tiredness
fatigue
Difficulty thinking
Difficulty concentrating (sometimes called “brain fog”)
Shortness of breath
difficulty breathing
Headache
Dizziness
Dizziness on standing
Fast-beating
pounding heart (known as heart palpitations)
Chest pain
Cough
Joint pain
muscle pain
Depression
anxiety
Fever
Loss of taste
Loss of smell
heart
lungs
kidneys
skin
brain
Lung damage
Heart damage, (including inflammation of the heart muscle)
Kidney damage
Neurological damage
Damage to the circulatory system resulting in poor blood flow
Other
Other
PLease Check all that apply
What resources did you use to take care of yourself during your infection?
Number of people you were/are around in the last 24Hrs?
0
1 to 3
4 to 6
More then 6
The number of Hrs you spent with people in the last 24Hrs?
0 Hrs
15 min to 5 Hrs
5 to 10 Hrs
More then 10 Hrs
Counting yourself, was everyone there wearing a mask and social distancing?
Yes
No
Not Applicable
Additional Notes
I would like to share the above note with others
Yes share this note
What medical care was provided to you?
What are you doing today to prevent from being sick from COIVD-19?
If you are human, leave this field blank.
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