Protocol - Long COVID - Comorbidities and COVID-19 Impact

Lifestyle & Pre-existing Conditions

1. Did you have any of these pre-existing conditions/diagnoses or did you experience any of the following pre-COVID?

[ ] Food Allergies

[ ] Environmental Allergies (dust, mold)

[ ] Chemical Allergies

[ ] Seasonal Allergies

[ ] Allergies of unknown origin

[ ] Other allergies

[ ] Insomnia

[ ] Lucid dreams (dreams where you are aware you are dreaming or have some control over what you dream)

[ ] Nightmares

[ ] Vivid dreams

[ ] Night sweats

[ ] Sleep apnea

[ ] Acid Reflux Disease

[ ] Celiac Disease

[ ] Crohn's Disease

[ ] Ulcerative Colitis

[ ] Irritable Bowel Syndrome (IBS)

[ ] Other GI issues

[ ] Asthma

[ ] COPD

[ ] Tuberculosis

[ ] Eczema

[ ] Viral skin conditions (cold sores, herpes, warts, molluscum)

[ ] Dementia

[ ] Seizures/epilepsy

[ ] Migraine

[ ] ALS

[ ] Parkinson's disease

[ ] Multiple Sclerosis

[ ] Peripheral neuropathy

[ ] Coronary Heart Disease

[ ] Heart failure

[ ] Hypertension (high blood pressure)

[ ] Hypotension (low blood pressure)

[ ] History of clotting

[ ] History of strokes

[ ] High cholesterol / hyperlipidemia

[ ] Mitral valve prolapse

[ ] Anemia

[ ] Autism

[ ] Auto-immune/rheumatological conditions

[ ] Cancer (all types)

[ ] Chronic kidney disease

[ ] Diabetes Type 1

[ ] Diabetes Type 2

[ ] Ehlers-Danlos Syndrome (EDS)

[ ] Endometriosis

[ ] Fibromyalgia

[ ] IgA deficiency

[ ] Interstitial Cystitis (Bladder Pain Syndrome)

[ ] Hepatitis (A/B/C)

[ ] HIV

[ ] Mast Cell Activation Syndrome (MCAS)

[ ] Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS)

[ ] Obesity

[ ] Postural Orthostatic Tachycardia Syndrome (POTS)

[ ] Recurrent bacterial infections

[ ] Recurrent viral infections

[ ] Restless leg syndrome

[ ] TMJ (temporomandibular joint dysfunction)

[ ] Vertigo

[ ] Vision: near-sighted/far-sighted

[ ] Vitamin D deficiency

[ ] None of the above

2. Please indicate other pre-existing conditions/diagnoses not listed here. If multiple, please separate them with a comma. Please only list the conditions, no descriptions or explanations.

____________________________________

3. Did any of your pre-existing conditions change during the course of COVID-19 symptoms?

[ ] Yes, they got worse.

[ ] Yes, they got better.

[ ] Some got better, some stayed the same, some got worse (please add an explanation in the text boxes in the following page).

[ ] No, they stayed the same.

[ ] N/A (I did not have any pre-existing condition)

3a. If any of your pre-existing conditions got worse, please describe here. (optional)

____________________________________

3b. If any of your pre-existing conditions got better, please describe here. (optional)

____________________________________