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COVID-19 Symptom Checklist

Designed by Thomas A. Glass, Ph.D.
Version 7

Please complete this checklist of symptoms you may have experienced. Check all the symptoms you have had even if the symptom has gone away. Your answers are confidential. Your responses will help you by improving your communication with your health care provider. This information will help us to better understand and define the symptoms people are having.

Q.1
When did you first notice symptoms? *

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Q.2
What was the first symptom you noticed? *

Q.3
During this illness, how many days have you had a fever? *

A fever in an adult is a body temperature of 100 degrees F (37.7 C) or more taken with a thermometer in the mouth.

Days:

Q.4
Have you been to see a doctor or other health care professional about this illness? *

Q.5
Here are some symptoms that have been reported in patients with COVID-19. For each one, please check response that best describes whether you have had that symptom *

(1) A body temperature of 100 degrees or higher taken with a thermometer in the mouth is considered a fever. Temperature taken just after waking up should not be used.
(2) These symptoms are cause for serious concern. If you or someone else has one of these symptoms, call your doctor immediately or dial 9-1-1.

Never Yes, but not now Yes, Now Not sure
Fever (1)
Dry cough
Feeling tired or run down more than normal
Shortness of breath, trouble breathing (2)
Muscle aches, muscle pain or body aches
Chills or sweating
Loss of appetite
Coughing up phlegm
Stuffy nose (congestion with little sneezing)
Runny nose (congestion with sneezing)
Sore throat
Headache
Coughing up blood
Nausea or vomiting
Diarrhea
Abdominal or stomach pain
Dizziness or fainting
Sudden confusion, memory loss or loss of consciousness (2)
Loss of sense of taste or smell
Pink eye, also called conjunctivitis

Fever (1)

Dry cough

Feeling tired or run down more than normal

Shortness of breath, trouble breathing (2)

Muscle aches, muscle pain or body aches

Chills or sweating

Loss of appetite

Coughing up phlegm

Stuffy nose (congestion with little sneezing)

Runny nose (congestion with sneezing)

Sore throat

Headache

Coughing up blood

Nausea or vomiting

Diarrhea

Abdominal or stomach pain

Dizziness or fainting

Sudden confusion, memory loss or loss of consciousness (2)

Loss of sense of taste or smell

Pink eye, also called conjunctivitis

Q.6
For each symptom you have had, how severe was or is it? *

If the severity of a symptom has changed, choose the answer for the worse it got.

Does not apply (never had it) Mild Moderate Severe Prefer not to say
Fever
Dry cough
Feeling tired or run down more than normal
Shortness of breath, trouble breathing
Muscle aches, muscle pain or body aches
Chills or sweating
Loss of appetite
Coughing up phlegm
Stuffy nose (congestion with little sneezing)
Runny nose (congestion with sneezing)
Sore throat
Headache
Coughing up blood
Nausea or vomiting
Diarrhea
Abdominal or stomach pain
Dizziness or fainting
Sudden confusion, memory loss or loss of consciousness
Loss of sense of taste or smell
Pink eye, also called conjunctivitis

Fever

Dry cough

Feeling tired or run down more than normal

Shortness of breath, trouble breathing

Muscle aches, muscle pain or body aches

Chills or sweating

Loss of appetite

Coughing up phlegm

Stuffy nose (congestion with little sneezing)

Runny nose (congestion with sneezing)

Sore throat

Headache

Coughing up blood

Nausea or vomiting

Diarrhea

Abdominal or stomach pain

Dizziness or fainting

Sudden confusion, memory loss or loss of consciousness

Loss of sense of taste or smell

Pink eye, also called conjunctivitis

Q.7
Has a doctor or other health care professional told you that you have COVID-19? *

Q.8
Are there any other symptoms you have that seem important but are not on the list?

Type in a brief description of one or more additional symptoms you would like to share.

Q.9
Have you had a COVID-19 test? *

We are asking about a test for the presence of the virus, usually done by swabbing the back of the throat or inside of the nose. Sharing this information is optional and no further contact will occur regardless of your answer.

Q.10
If yes, have you had 1 or more positive tests for COVID-19?

Q.11
What has been your experience during this illness?

Feel free to include things you had trouble with, what your concerns are and what it has been like to seek help or manage your symptoms.

Q.12
Feel free to share any comments or feedback about this checklist.

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