How would you describe the fatigue?

a) Persistent, worsens significantly after physical or mental effort, and feels like a "crash".

b) Ongoing exhaustion, with no clear crash pattern.

c) Fatigue that comes and goes, along with weakness or tremors.

d) I don’t experience significant fatigue.

e) More than one of the above

When did your symptoms begin?

a) Gradually, with no clear trigger

b) After a confirmed or suspected COVID-19 infection or vaccine.

c) Suddenly, often after a physical injury, stress, or neurological event.

d) I’m not sure or no clear onset.

e) More than one of the above

Which of these issues do you experience most? *

a) Brain fog, difficulty concentrating and memory issues that worsen after activity.

b) Brain fog, headaches, or dizziness that persist since a COVID-19 infection.

c) Limb weakness, tremors, or non-epileptic seizures.

d) None of these.

e) More than one of the above

Do you experience these symptoms? *

a) Dizziness or rapid heart rate, especially after exertion.

b) Postural Orthostatic Tachycardia Syndrome (POTS)-like symptoms (e.g., rapid heart rate or dizziness when standing).

c) Fainting or irregular muscle movements or tremors.

d) Non of these

e) More than one of the above

How would you describe your pain or sensory symptoms? *

a) Muscle or joint pain, often without swelling, worsened by activity.

b) Pain or sensory changes (e.g., numbness, tingling) tied to specific neurological symptoms like limb weakness.

c) Muscle aches or neuropathic pain that started after a COVID-19 infection or vaccine

d) No significant pain or sensory issues.

e) More than one of the above

How are your sleep patterns affected? *

a) Sleep disturbances linked to neurological symptoms or stress.

b) New or worsened sleep issues (e.g., insomnia, poor sleep quality) since COVID-19/vaccine

c) Unrefreshing sleep, taking longer to fall asleep, or disrupted REM sleep.

d) No significant sleep issues.

e) More than one of the above

How do cognitive issues affect your daily life? *

a) Severe brain fog and memory issues that significantly impair daily tasks after exertion.

b) No significant cognitive issues.

c) Cognitive issues tied to seizures or motor dysfunction.

d) Persistent brain fog or difficulty concentrating since a COVID-19 infection/vaccine.

e) More than one of the above

How does physical activity affect you? *

a) Activity may trigger neurological symptoms like weakness or tremors, but not always fatigue.

b) Minor activity causes severe symptom worsening (PEM) lasting days or weeks.

c) Physical activity worsens symptoms but not always with a clear crash pattern.

d) I tolerate physical activity well.

e) More than one of the above

Which additional symptoms do you experience?

a) Sore throat, tender lymph nodes, or flu-like symptoms recurring frequently.

b) Shortness of breath, heart palpitations, or new sensitivities to food/smells

c) Functional symptoms like difficulty swallowing, speech issues, or sensory changes.

d) None of these.

e) More than one of the above

How has your condition affected your mood? *

a) Anxiety or depression due to chronic illness but not the primary issue.

c) Mood changes tied to neurological symptoms or stress triggers.

c) New or worsened anxiety/depression since COVID-19, often with physical symptoms.

d) No significant mood changes.

e) More than one of the above

Full Name *

Email *

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