COVID INSTITUTE

Name:

Long COVID Self-Assessment

1. Top 5 Symptoms I Struggle With the Most

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2. What Makes My Symptoms Worse?

Activity Triggers:

Walking or physical activity

Standing still

Mental effort (reading, screens, talking)

Emotional stress

After doing too much (next-day crash or "PEM")

Environment Triggers:

Heat (hot showers, weather, saunas)

Cold

Loud noises or busy places

Food Triggers:

Meals in general

Carbohydrate-heavy meals (bread, pasta, sugar)

Fermented foods (yogurt, wine, kombucha)

Spicy foods or leftovers

3. Past Treatments or Strategies

Things I've tried that helped:

Things I tried that made me feel worse:

Supplements or medications I'm currently taking:

4. Medical History

Check all that apply:

I had COVID-19 more than once

I had symptoms during acute COVID (fever, cough, fatigue, etc.)

I had five or more symptoms in the first week of COVID

I had a history of fatigue or poor recovery before COVID

I am on blood thinners:

Diagnosed with:

POTS or other dysautonomia

ME/CFS (chronic fatigue syndrome)

Mast Cell Activation Syndrome (MCAS)

Autoimmune disease (e.g., lupus, rheumatoid arthritis)

Lyme disease

Gut disorders (IBS, SIBO, Crohn's, etc.)

Anxiety, panic attacks, or trauma history

5. What I Hope to Improve Most

In one or two sentences, describe your top goals for healing or recovery:

6. Notes or Patterns I've Noticed

Save Your Assessment

Click the button below to print your completed assessment:

Instructions:

1. Fill in your name at the top of the form

2. Complete each section thoroughly, checking boxes and filling in text fields as applicable

3. Use the print button to save your assessment

4. Share this comprehensive assessment with your healthcare provider for better care coordination

We are dedicated to the diagnosis, treatment, and management of Long Covid / Vaccine Injury Symptoms.

Note: Nothing posted on this website is considered medical advice, to treat or cure any condition or disease. Please use at your own risk. For information use only.

Treatments

Gut Dysbiosis

Stellate Ganglion Block

Vagus Nerve Stimulation

Mitochondria Dysfunction

MCAS/ Excess Histamine Treatment

Epipharyngeal Abrasive Therapy (EAT)

Contact Us

| (214) 390-7557

| 6957 W Plano Pkwy, Suite 2100, Plano, TX 75093