Version 1.0 September 2021

The Symptom Burden Questionnaire™ for Long COVID (SBQ™-LC) asks for your views about your symptoms and their impact on daily life over the last 7 days.

It will take approximately 15-20 minutes to complete all the scales.

For each scale, please answer ALL the questions. Please rest and take breaks if needed.

Thank you for completing this questionnaire.


Breathing

These questions are about your BREATHING symptoms. For each question, please choose the response that best describes your experience over the last 7 days.


Pain

These questions are about your PAIN symptoms. For each question, please choose the response that best describes your experience over the last 7 days


Circulation

These questions are about your CIRCULATION symptoms. For each question, please choose the response that best describes your experience over the last 7 days.


Fatigue

These questions are about your FATIGUE symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Memory, Thinking and Communication

These questions are about your MEMORY, THINKING, AND COMMUNCATION symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.

Movement

These questions are about your MOVEMENT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Sleep

These questions are about your SLEEP symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Ear, Nose & Throat

These questions are about your EAR, NOSE, AND THROAT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Stomach & Digestion

These questions are about your STOMACH AND DIGESTION symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Muscle & Joints

These questions are about your MUSCLE AND JOINT symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Mental Health & Wellbeing

These questions are about your MENTAL HEALTH AND WELLBEING symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.

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Skin & Hair

These questions are about your SKIN AND HAIR symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Eyes

These questions are about your EYE symptoms. Please answer ALL the questions, thinking about your symptoms over the last 7 days.


Female Reproductive & Sexual Health

These questions are about your FEMALE REPRODUCTIVE AND SEXUAL HEALTH symptoms. Please answer ALL the questions thinking about your symptoms over the last 7 days. 

Please feel free to leave this section if you do not feel comfortable answering these questions.  


Male Reproductive & Sexual Health

These questions are about your MALE REPRODUCTIVE AND SEXUAL HEALTH symptoms. Please answer ALL the questions thinking about your symptoms over the last 7 days. 

Please feel free to leave this section if you do not feel comfortable answering these questions.   



Other Symptoms

These questions are about your OTHER SYMPTOMS. Please answer ALL the questions thinking about your symptoms over the last 7 days.


Impact on Daily Life

For EACH question, please select one answer that best describes how your symptoms have affected you in the last 7 days. Please answer ALL the questions.


If YES, which other symptom(s) do you wish to report?


Thank you for taking the time to complete this questionnaire.


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