RIPPLE FUNCTIONAL WELLNESS & CRUSH COVID 2021 PRESENT

COVID-19 Long Hauler Symptom Survey

I want to hear how COVID-19 has changed your life.

As a COVID long hauler I understand how devastating these symptoms are. As a Functional Medicine Certified Health Coach I have the knowledge and tools to help you and I want to share that knowledge with you!

I see you. I hear you. I want to know your story. Thank you for sharing it with me.

- Natalie
CEO, Ripple Functional Wellness (Ripple Functional Wellness)
Founder, Crush Covid 2021 (Crush Covid 2021)

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* 1. What is your age range?

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* 2. What is your gender?

Female

Male

Non-Binary

I'd rather not say

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* 3. When did you contract COVID-19?

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* 4. How many days did you experience primary symptoms?

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* 5. Were any other members of your household sick?

Yes

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* 6. Did you have a COVID-19 nasal swab test?

Yes

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* 7. Did you test positive?

Yes

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* 8. Did anyone else in your household test positive?

Yes

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* 9. What symptoms did you have when you were sick?

Fever

Sore Throat

Chills

Fatigue

Weakness

Insomnia

Cough

Shortness Of Breath

Brain Fog

Headaches

Migraines

Muscle Pain

Vomiting

Diarrhea

Other (please specify)

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* 10. What LONG HAUL symptoms are you currently experiencing (Check all that apply)?

Shortness of Breath

Muscle Weakness

Tremors

Heart Palpitations

High Blood Pressure

Low Blood Pressure

Chest Constriction

Rib pain

Back pain

Leg pain

Nausea

Vomiting

Headaches

Migraines

Weight Gain

Weight Loss

Hair loss

Loss of smell

Loss of taste

Loss of Sex Drive

Erectile Dysfunction

Depression

Anxiety

Paranoia

Other (please specify)

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* 11. Does your primary care believe you have long haul symptoms?

Yes

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* 12. Have you seen any specialists regarding your long haul symptoms? If so, what Speciality?

Cardiologist

Rheumatologist

Endocrinologist

Gastroenterologist

Hematologist

Psychologist

Psychiatrist

Infectious Disease Specialist

Internist

Nuerologist

Other (please specify)

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* 13. Did you have any pre-existing diseases/disorders/syndome(s)?

Chronic Fatigue Syndrome

Fibromyalgia

Multiple Sclerosis

Restless Leg Syndrom

Heart Disease

Lung Disease

Kidney Disease

Liver Disease

COPD

Cancer

Parkinsons

Type 1 Diabetes

Type 2 Diabetes

Cirrhosis

HIV

Blood disorder

Other (please specify)

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* 14. Have your long haul symptoms made your pre-existing condition(s) worse?

Yes

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* 15. How have your long haul symptoms affected your life?

Not At All

Somewhat

Life Altering

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 16. Have your long haul symptoms affected your ability to work?

Not At All

Somewhat

I Quit/I WasFired

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 17. What was your activity level BEFORE contracting Covid-19?

Couch Potato

I Like To Move It, Move It!

Hard Core Athlete

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 18. What is your activity level now?

I Can't Get Out Of Bed

Moving, But Not Like I Used To

I'm Stronger Than Ever!

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 19. What would you like the world to know about what it's like to be a COVID Long Hauler?

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* 20. Please share your information so your story can be heard and to gain access to our
exclusive CLH Ripple FB Group!

Name

City/Town

Country

Email Address

RIPPLE FUNCTIONAL WELLNESS & CRUSH COVID 2021 PRESENT

COVID-19 Long Hauler Symptom Survey

Question Title

* 1. What is your age range?

Question Title

* 2. What is your gender?

Question Title

* 3. When did you contract COVID-19?

Question Title

* 4. How many days did you experience primary symptoms?

Question Title

* 5. Were any other members of your household sick?

Question Title

* 6. Did you have a COVID-19 nasal swab test?

Question Title

* 7. Did you test positive?

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* 8. Did anyone else in your household test positive?

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* 9. What symptoms did you have when you were sick?

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* 10. What LONG HAUL symptoms are you currently experiencing (Check all that apply)?

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* 11. Does your primary care believe you have long haul symptoms?

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* 12. Have you seen any specialists regarding your long haul symptoms? If so, what Speciality?

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* 13. Did you have any pre-existing diseases/disorders/syndome(s)?

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* 14. Have your long haul symptoms made your pre-existing condition(s) worse?

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* 15. How have your long haul symptoms affected your life?

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* 16. Have your long haul symptoms affected your ability to work?

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* 17. What was your activity level BEFORE contracting Covid-19?

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* 18. What is your activity level now?

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* 19. What would you like the world to know about what it's like to be a COVID Long Hauler?

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* 20. Please share your information so your story can be heard and to gain access to our exclusive CLH Ripple FB Group!

* 20. Please share your information so your story can be heard and to gain access to our
exclusive CLH Ripple FB Group!