Coronavirus COVID-19 and Viral Illness Questions

 

Following is a list of the questions in the Paradigm Change Coronavirus COVID-19 and Viral Illness Survey.

 

Read About The Survey

 

Take The Survey

 

Introduction

This anonymous survey has the goal of collecting information from individuals who believe that there is a possibility that they have experienced illness symptoms as a result of being infected with the coronavirus COVID-19.

The survey was developed by Lisa Petrison, Ph.D, and is presented by Paradigm Change.

About The Illness:

COVID-19 may manifest differently in different people, depending on the level of severity and other factors.

Therefore, please go ahead and fill out this survey if you have experienced any kind of acute viral-type illness since December 1, 2019, even if you are not convinced that it was COVID-19 rather than something else.

Also, if you had an illness prior to December 1, 2019, and believe that it may have been COVID-19, please feel free to fill out the questionnaire focusing on that illness.

More information about the survey may be found at this link:

https://paradigmchange.me/wp/coronavirus-survey/

Although you may take the survey on a smart phone or pad, a desktop or laptop computer may be a bit faster if you have one available.

All questions in the survey are optional.

Thank you very much for participating in this survey!

To go to the next page, please click the Arrow button (or the “Next” button”) below.

 

Survey Subject

You may fill out this survey based either on your own illness experiences or on behalf of someone else.

Please feel free to fill out this survey multiple times, focusing on a different individual each time.

You also may update the information that you provide later on, as the person’s health situation progresses.

 

Participating On Behalf of Another Adult

Those who would like to fill out the survey on behalf of another adult are requested to ask for consent from that individual if he or she is well enough to grant it.

Family members may fill out the survey for those individuals who are too ill to grant permission or who have died.

 

Participating On Behalf of a Child

Parents or legal guardians may fill out surveys on behalf of their children (or with their children’s participation).

Individuals under age 18 are not allowed to fill out the survey without the participation of their parents or legal guardians.

 

Updating Your Responses

Individuals who fill out the survey may want to provide more information about their experiences as their health situations unfold.

So that updated information may be matched with original information provided, a Patient Nickname should be chosen for each individual patient being discussed.

 

Use Of The Word “You”

Throughout this survey (except for Q1 and Q2), the word “You” should be taken to refer to the person (either yourself or someone else) on whose behalf you are filling out the survey.

 

Q1.  Are you filling out this survey on behalf of yourself or someone else?

On my own behalf

On behalf of another adult, with their permission

On behalf of an adult family member who is too sick to give permission

On behalf of my child, who is under age 18

On behalf of a family member who has died

 

Q2.  Is this your first time filling out the survey for this person?

This is my first time filling out the survey for this person.

I already have filled out a survey for this person but don’t remember the Patient Nickname.

I have already filled out a survey for this person and the Patient Nickname is ____________.

 

Q3.  Please choose a Patient Nickname for the person who is the focus of this survey response (yourself or someone else) and write it in the box below.

So that privacy will be protected, please do not use this person’s real name.

Please make an effort to remember the Patient Nickname so that you can provide updates later on if you choose.

 

Suspect Illness Definition

Please consider any acute viral-type illnesses that you have had since December 1, 2019.

If you have had multiple illnesses tat seem to have been distinctly separate from one another, please focus on the one that seems most likely to have been caused by the coronavirus COVID-19.

This particular viral-type illness will be referred to as the “Suspect Illness” in this questionnaire.

Note: If you had a particular viral-type illness prior to December1, 2019, that you have reason to believe may have been COVID-19, you may answer the questions with regard to that illness.

 

Q4. What was the date when you FIRST started experiencing symptoms of the Suspect Illness?

If you are not sure of the date, please provide your best guess.

On the computer version, please use the following format: MM/DD/YYYY

For instance, 02/28/2020

 

Q5. What country were you in when you first started experiencing symptoms of the Suspect Illness?

 

Q6. What state or province were you in when you first started experiencing symptoms of the Suspect Illness?

 

Q7. What town were you in when you first started experiencing symptoms of the Suspect Illness?

Note: If you would prefer not to state the specific town, then you can provide a more general description such as “Chicago area” or “Northeast Arizona.”

 

Q8. Please feel free to supply more details about the location and the date of the onset of the Suspect Illness here.

Note: For all essay questions in this survey, you may write or paste as much as you like in the box.

 

Q9.  What towns did you spend time in during the two weeks PRIOR to first experiencing symptoms of the Suspect Illness?

You can use a general description (such as “Chicago area” or “Northeast Arizona”) to protect your privacy if you like.

 

Q10. What towns have you spent time in WHILE experiencing symptoms of the Suspect Illness?

You can use a general description (such as “Chicago area” or “Northeast Arizona”) to protect your privacy if you like.

 

Q11.  What symptoms did you experience during the first two days of the Suspect Illness?

 

Q12. All in all, how problematic have lung symptoms (related to coughing, breathing or chest pain) been for you during the Suspect Illness?

Life-threatening problem

Very severe problem

Severe proble

Moderate problem

Mild problem

Very mild problem

I didn’t experience lung symptoms

 

Q13. What was the date when you FIRST started experiencing significant coughing, breathing issues or lung pain?

If you are not sure of the ate, please provide your best guess.

On the computer version, please use the following format:  MM/DD/YYYY

For instance, 02/28/2020

 

Q14.  How much of an issue has each of these lung symptoms been for you so far with regard to the Suspect Illness?

Response Options:

Life-threatening issue

Very severe issue

Severe issue

Moderate issue

Mild issue

Not an issue

Symptoms:

Difficulty breathing

Shortness of breath

Lung or chest pain

Feelings of lung or chest pressure

Dry cough (without phlegm)

Wet cough (with phlegm)

Pneumonia

Bronchitis

 

Q15. How much of an issue has each of these other symptoms been for you so far with regard to the Suspect Illness?

Response Options:

Life-threatening issue

Very severe issue

Severe issue

Moderate issue

Mild issue

Not an issue

Symptoms:

Headache

Sore or painful throat

Difficulties with swallowing

Difficulties with talking (sore voice)

Dehydration

Diarrhea

Vomiting

Feelings of nausea

Loss of appetite (anorexia)

Loss of sense of smell

Loss of sense of taste

Abdominal pain

Blue lips or face

 

Q16. How much of an issue has each of these other symptoms been for you so far with regard to the Suspect Illness?

Response Options:

Life-threatening issue

Very severe issue

Severe issue

Moderate issue

Mild issue

Not an issue

Symptoms:

Elevated temperature (fever)

Feverish feelings

Chills

Muscle aches

Bone pain

Joint pain

Pain wen moving body parts

Runny or stuffy nose

Sneezing

Weakness

Tiredness

Sleepiness

Generally feeling terrible

 

Q17.  Please list other symptoms of the Suspect Illness that have been at least moderately problematic for you in this box.

You may list as many symptoms as you like.

 

Q18. Compared to what things were like when the Suspect Illness was at its worst, how are you doing now?

I feel totally recovered

I feel mostly recovered

I feel somewhat recovered

I feel a little better but not recovered

I don’t feel any better but the situation feel like it is stable

I don’t feel any better and the situation feels like it is getting worse

I feel basically recovered from the acute viral symptoms, but other chronic illness issues are worse than before I got the Suspect Illness

Other – Write In

 

Q19. Please describe the chronic illness issues that are worse now than they were before you acquired the Suspect Illness.

 

Q20.  Were you bedridden for a day or more as a result of the Suspect Illness?

Totally bedridden

Almost totally bedridden

Mostly bedridden

Not really bedridden but slept a great deal

Not bedridden

I already was mostly or fully bedridden before getting the Suspect Illness

 

Q21.  To your knowledge, what was the highest body temperature that you experienced during the Suspect Illness?

Higher than 104F (40C)

Between 103-104F (39.4-40C)

Between 102-103F (38.9-39.4C)

Between 101-102F (38.3-38.9C)

Between 100-101F (37.8-38.2C)

Between 99-100F (37-37.8C)

Lower than 99 F (37 C)

Don’t know

 

Q22. A normal body temperature is usually defined as about 97.7-99.5 F (36.5-37.5 C).

Prior to acquiring the Suspect Illness, what was your usual body temperature?

Lower than the normal range

Within the normal range

Higher than the normal range

Variable

Don’t know

 

Q23.  A relapse is when a person seems to be getting better from an illness but then gets substantially worse again.

Which of these statements best describes your relapse experiences with the Suspect Illness?

I have not yet experienced improvements

I have experienced improvements without substantial relapses

I got somewhat better but then had a substantial relapse

I felt like I was basically recovered but then had a substantial relapse

I’m not sure

 

Q24.  Please feel free to share details about your relapse experiences.

 

Q25. Please provide your best guess with regard to the NUMBER OF DAYS so far that the Suspect Illness has been life-threatening, very severe, severe, moderate or mild.

You may feel free to provide a very rough estimate or to skip this question entirely if you prefer.

 

Q26. Have you discussed your Suspect Illness with a physician or other licensed healthcare provider?

* Yes, I saw a practitioner

* Yes, I discussed with a practitioner via phone or Internet

* No

* Other – Write In

 

Q27.  Did you receive a test for the coronavirus COVID-19?

Yes, and the test results were positive

Yes, and the test results were negative

Yes, and the test results were inconclusive

Yes, and I am waiting for the results

No, I have not received a test

Other – Write in

Q28.  What diagnosis or other information about your condition did your healthcare provider give you?

 

Q29. Please feel free to provide additional information about your medical treatment here.

 

Q30. Which of the following explains why you have not seen a healthcare provider for the Suspect Illness?

Please check as many reasons as apply.

Have appointment scheduled

Not able to get an appointment

Practitioner advised me not to come in

Don’t have a primary care provider nearby

Don’t have a primary care provider at all

Concerned about exposure to infections

Concerned about exposure to mold or chemicals

Concerned about out-of-pocket costs

Concerned about being quarantined

Concerned about infecting others

Illness has not been severe enough

Too much trouble

Feel too sick to make the effort

Unable to arrange transportation to doctor or hospital

Doubt that practitioner would be able to help

Avoid healthcare practitioners in general

Other – Write In

 

Q31.  What country do you currently call home?  (If unsure:  Please list the country where you have spent the most time during the past six months.)

 

Q32.  What state or province do you currently call home?   (If unsure:  Please list the state or province where you have spent the most time in the past six months.)

 

Q33.  What is your gender?

Female

Male

Non-binary

 

Q34.  What decade were you born?

1910’s

1920’s

1930’s

1940’s

1950’s

1960’s

1970’s

1980’s

1990’s

2000’s

2010’s

 

Q35.  During the few months prior to getting the Suspect Illness, where had you been living or staying?  Please check all that apply.

House

Townhouse

Apartment

Shed or Garage

Porch or Balcony

Retirement Facility

Assisted Living Facility

Nursing Facility

Hospital

Dormitory

Military Barracks

Prison

RV (with plumbing)

Vehicle (without plumbing)

Tent

No Shelter

Other – Write In

 

Q36. In recent years, not counting the Suspect Illness, how often on average have you gotten colds or flus?

Several per year

One or two per year

One every couple of years

One every several years

Rarely or never

Not sure

 

Q37.  Compared to colds or flus that you have had in the past, what has the Suspect Illness been like for you?  Please check all that apply.

The Suspect Illness has had different symptoms than typical colds or flus.

The Suspect Illness has been more severe than typical colds or flus.

The Suspect Illness has been harder for me to get over than typical colds or flus.

 

Q37A. Had you received a flu shot at any time in the year or so prior to getting the Suspect Illness?

Yes, I definitely received a flu shot during that time.

Yes, I think that I received a flu shot but am not certain.

No, I don’t think that I received a flu shot but am not certain.

No, I definitely did not receive a flu shot.

I don’t know

 

Q38.  A normal blood pressure reading is often defined as between 100/60 and 120/80.

Keeping this in mind, was your typical blood pressure before acquiring the Suspect Illness high, normal or low?

Very high

High

Normal

Low

Very low

Don’t know

 

Q39. Prior to acquiring the Suspect Illness, were you taking medication to raise or lower your blood pressure?

Yes, I was taking medication to lower my blood pressure.

Yes, I was taking medication to raise my blood pressure.

No, I was not taking medication to lower my blood pressure.

Don’t know.

 

Q40.  Which of the following chronic health conditions have you had at any point in your life?

Abbreviations:  ADD = Attention Deficit Disorder; ADHD = Attention Deficit Hyperactivity Disorder; ALS = Amyotrophic Lateral Sclerosis (or Motor Neurone Disease); ASD = Autism Spectrum Disorder; GWI = Gulf War Illness; IBD = Inflammatory Bowel Disease; IBS = Irritable Bowel Syndrome; ME = Myalgic Encephalomyelitis; ME/CFS = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; MCAS = Mast Cell Activation Syndrome; MCS = Multiple Chemical Sensitivities; MS = Multiple Sclerosis; POTS = Postural Orthostatic Tachycardia Syndrome; CIRS = Chronic Inflammatory Response Syndrome

 

ADD or ADHD

ALS

Alzheimer’s

ASD

Asthma

Autoimmune Illness

Chronic Lyme or Post Lyme syndrome

Diabetes

Fibromyalgia

Gluten or food sensitivities

GWI

Heart disease

IBD

IBS

Lung disease

ME or ME/CFS

MCAS

MCS

MS

Parkinson’s

POTS

Psychiatric issues

Toxic Mold Illness or CIRS

None of the above

 

Q41.  Please list any other chronic health conditions that you have experienced.

 

Q42.  Which of these psychiatric conditions have you experienced?

Major depressive disorder

Bipolar disorder

Anxiety disorder

Obsessive-compulsive disorder

Post traumatic stress disorder

Psychotic or schizophrenic disorder

Other – Write In

 

Q43.  Now, please think back to any neurological problems you may have experienced during your life.  These may have included memory problems, other kinds of cognitive impairments, psychiatric issues, seizures, convulsions, paralysis or any other kind of neurological problem. At their worst, how severe were these neurological problems?

Very severe

Moderately severe

Moderate

Mild

I have not experienced these kinds of symptoms

I’m not sure

 

Q44. Please think back to the six months when you were the MOST SICK with any kind of chronic illness issues. How much of a problem were the following symptoms for you at that time?

Options:

Very Severe Problem

Severe Problem

Moderate Problem

Mild Problem

Not A Problem

Symptoms:

Feeling worse after activity or exercise

Cognitive issues (difficulties thinking or remembering)

Difficulties with sitting or standing (due to POTS, OI or low blood pressure)

Headaches

Muscle or joint pain

Unrefreshing sleep

Sensitivities to mold, chemicals, EMF’s or foods

 

Q45. Please think back to the six months in your life when you were the MOST affected by any kind of neurological or other chronic illness issues.  During that time, how much activity did your health regularly allow?  Please choose the one statement that describes what your life was like then.

I could work or be active for 60 hours a week or more.

I could work or be active for 50 hours a week or more.

I could work or be active for 40 hours a week or more.

I could work or be active for 30 hours a week or more.

I could work or be active for 20 hours a week or more.

I could work or be active for 10 hours a week or more.

I could go out to shop or socialize aa few times a week.

I rarely could go out to shop or socialize, but I was not bedridden.

I was basically bedridden but frequently could read or participate in conversations.

I was totally bedridden and rarely could read or participate in conversations.

 

Q46.  Now, please think back to the six months JUST PRIOR to getting the Suspect Illness. During that time, how much activity did your health regularly allow? Please choose the statement that best describes what your life was like then.

I could work or be active for 60 hours a week or more.

I could work or be active for 50 hours a week or more.

I could work or be active for 40 hours a week or more.

I could work or be active for 30 hours a week or more.

I could work or be active for 20 hours a week or more.

I could work or be active for 10 hours a week or more.

I could go out to shop or socialize aa few times a week.

I rarely could go out to shop or socialize, but I was not bedridden.

I was basically bedridden but frequently could read or participate in conversations.

I was totally bedridden and rarely could read or participate in conversations.

 

Q47.  Have you made any efforts to avoid exposures to environmental mold toxins?

Yes, I have made a big effort

Yes, I have made some effort

No, I have not pursued that

Not sure

 

Q48.  Please think back to how you were feeling during the several months before getting sick with the Suspect Illness. All in all, had your health improved since you started avoiding mold?

Yes, it had improved a great deal

Yes, it had improved somewhat

No, it had stayed about the same

No, it had gotten worse

Not sure

I was not able to be avoiding mold then

 

Q49.  How good are you at immediately sensing or guessing whether you are currently being exposed to environmental mold toxins that will turn out to be a problem for you?

Extremely good

Very good

Fairly good

Not that great

I’m not able to do that at all

I’m not sure

 

Q50.  During the Suspect Illness, how clear have you been of mold toxins that typically have a negative effect on you?

Very clear

Mostly clear

Somewhat clear

Not very clear

Not clear at all

Not sure

 

Other Household Members

The next questions ask about the health of other members of your household.

Please answer the questions for each individual who is living in the same home as you, regardless of their health status.

In addition, if you regularly spend time with specific other individuals (such as parents or romantic partners) who are in your intimate family circle, then please answer the questions for them even if they are not usually sleeping under the same roof as you.

You may answer for up to 10 individuals total.

 

Q51.  Are there any household members to discuss?

Yes

No

 

Q52. What year was this individual born? If you are not sure, please provide your best guess.

 

Q53.  Please briefly describe any chronic health conditions this person has.

 

Q54.  Has this person been sick with any viral-type illness that included lung issues (such as coughing, breathing problems or lung pain) since December 1, 2019?

Yes, with a life-threatening illness

Yes, with a very severe illness

Yes, with a moderately severe illness

Yes, with a moderate illness

Yes, with a mild illness

No, there was an illness but without significant lung issues

No, there was no illness

I’m not sure

 

Q55.  Is there another member of the household to discuss?

Yes

No

 

Q56.  The next section of this survey looks at whether various treatments that you may have tried were helpful to you with regard to the Suspect Illness. This section of the survey is optional. Would you like to answer these questions?

Yes, I would like to answer these questions.

No, I would like to skip these questions

 

Q57.  How helpful has each of the following nutrients seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

 

Treatment:

Vitamin A

Vitamin C

Vitamin D

Vitamin E

Iodine

Quercetin

Selenium

Zinc

Q58.  How helpful has each of the following botanicals seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatment:

Berberines (e.g. Goldenseal)

CBD

Curcumin

Echinacea

Elderberry

Essential Oils – Garlic

Essential Oils – Oregano

Essential Oils – Other

Garlic Pills

Marijuana

 

Q59.  How helpful has each of the following other supplements seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatments:

Colloidal Silver

Medicinal Mushrooms

Melatonin

Monolaurin

Probiotics

Transfer Factor

 

Q60.  How helpful has each of the following foods or beverages seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatment:

Alcohol

Citrus fruits

MCT or coconut oil

Electrolyte beverage (e.g. Gatorade)

Garlic

Ginger

Hot peppers

Onions

Raw honey

Q61.  How helpful has each of the following prescription medicines seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatments:

Antibiotic drugs – Azithromycin (e.g. Z-pack)

Antibiotic drugs – Other

Antifungal drugs

Antiviral drugs

Chloroquine

Cortisol or cortisone

Cough syrup (prescription)

Hydroxychloroquine (e.g. Plaquenil)

Lopinavir/Ritonavir (e.g. Kaletra)

Nitazoxanide (e.g. Alinia)

Q62.  How helpful has each of the following non-prescription medications seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatments:

Acetaminophen or paracetamol (e.g. Tylenol)

Aspirin

Cough drops

Cough syrup (non-prescription)

Ibuprofen (e.g. Advil)

Vicks VapoRub

 

Q63.  How helpful has each of the following lifestyle interventions seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatments:

Bathe and change clothes frequently

Reduce stress

Rest

Spend time outdoors in good locations

Stay out of moldy buildings

Stay warm

Sun exposure

Take warm/hot baths

 

Q64.  How helpful has each of the following nutrients seemed to be with regard to helping you cope with or recover from the Suspect Illness? If you did not try a treatment, you may either state that or just leave the item blank.

Scale:

Critically Important

Very Helpful

Somewhat Helpful

No Effect

Harmful

Don’t Know

Didn’t Try

Treatments:

Coffee enemas

Gargling

Nebulizer

Onion poultice

Ozone therapy

Rife

Rinsing sinuses

Salt pipe with iodine

Ventilator

Q65.  Please list any other treatments that you found to be Critically Important or Very Helpful in this box.  You may list as many treatments as you like.

 

Q66. Please provide information on the amount of Vitamin C that you used.

 

Q67.  Please provide information on the amount and type of zine that you used.

 

Q68. Please provide information on how you used the garlic essential oil.

 

Q69.  Please provide information on the essential oils that you used as well as on the method of administration (e.g. inhaled or ingested).

 

Q70.  Please provide information on how you used the colloidal silver.

 

Q71.  Please provide information on the type of transfer factor you used.

 

Q72.  Please provide information on the antibiotics you used.

 

Q73. Please provide information on the antifungals you used.

 

Q74.  Please provide information on antivirals used.

 

Q75. Please provide information on how you used the melatonin.

 

Q76. Please provide information on what you used for gargling.

 

Q77.  Please provide information on the specific substances you used in the nebulizer.

 

Q78. Please provide information on the type of ozone therapy you used.

 

Q79.  Please provide information on what you used to rinse your sinuses.

 

Q80.  Please feel free to share other information about treatments that you pursued with regard to the Suspect Illness.  You may type or paste as much as you like in this box.

 

Q81.  Please feel free to share a summary of your experiences with the Suspect Illness or provide other information about it.  You may type or paste as much as you like in this box.

 

Q82.  Please share any additional comments that you may have.

This is the last question. After you press “Submit” at the bottom of the page, you will not be able to go back and change answers.

 

Thank You!

Thank you very much for participating in this survey.

I appreciate your time and wish you the best with regard to your future health issues.

 

If you have any questions about the survey, you may contact me at:

info@paradigmchange.me

 

Best regards,

Lisa Petrison, Ph.D.

Paradigm Change

www.paradigmchange.me