COVID-19 Yorkshire Rehabilitation Screening Tool v2

COVID-19 Yorkshire Rehabilitation Screening Tool v2

Following on are some questions about how you might have been affected since your illness. 

If there are other ways that you've been affected, then there will be a chance to describe these at the end. 

  • Patient Details

    Patient date of birth
    For example, 15 3 1984

  • Breathlessness

    At rest, - Now: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you: (optional)
    At Rest - Pre Covid: On a scale of 0-10 with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you: (optional)
    On dressing yourself - now: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity) (optional)
    On dressing yourself - pre-covid: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (N/A if does not perform this activity) (optional)
    On walking up a flight of stairs - now: on a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity) (optional)
    On walking up a flight of stairs - pre-covid: On a scale of 0-10, with 0 being not breathless at all, and 10 being extremely breathless, how breathless are you (n/a if does not perform this activity) (optional)

  • Laryngeal/Airway Complications

    Have you developed any changes in the sensitivity of your throat such as troublesome cough or noisy breathing? (optional)
    If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact) (optional)

  • Voice

    Have you or your family noticed any changes to your voice such as difficulty being heard, altered quality of the voice, your voice tiring by the end of the day or an inability to alter the pitch of your voice? (optional)
    If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact) (optional)

  • Swallowing

    Are you having difficulties eating, drinking or swallowing such as coughing , choking or avoiding any food or drinks? (optional)
    If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact) (optional)

  • Nutrition

    Are you or your family concerned that you have ongoing weight loss or any ongoing nutritional concerns as a result of COVID-19? (optional)
    Please rank your appetite or interest in eating on a scale of 0-10 since COVID-19 (0 being the same as usual/no problems, 10 being very severe problems/reduction) (optional)

  • Mobility

    On a 0-10 scale, how severe are any problems you have in walking about? - Now (0 means I have no problems, 10 means I am completely unable to walk) (optional)
    On a 0-10 scale, how severe are any problems you have in walking about? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to walk) (optional)

  • Fatigue

    Do you become fatigued more easily compared to before your illness? (optional)
    If yes, how severely does this affect your mobility, personal cares, activities or enjoyment of life? - Now (0 being not affecting, 10 being very severely impacting) (optional)
    If yes, how severely does this affect your mobility, personal cares, activities or enjoyment of life? - Pre-Covid (0 being not affecting, 10 being very severely impacting) (optional)

  • Personal Care

    On a 0-10 scale, how severe are any problems you have in personal cares such as washing and dressing yourself? - Now (0 means I have no problems, 10 means I am completely unable to do my personal care) (optional)
    On a 0-10 scale, how severe are any problems you have in personal cares such as washing and dressing yourself? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to do my personal care) (optional)

  • Continence

    Since your illness are you having any new problems with: Controlling your bowel? (optional)
    Since your illness are you having any new problems with: controlling your bladder? (optional)

  • Usual Activities

    On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as your household leisure activities, work or study? - Now (0 means I have no problems, 10 means I am completely unable to do my usual activities) (optional)
    On a 0-10 scale, how severe are any problems you have in doing your usual activities, such as your household leisure activities, work or study? - Pre-Covid (0 means I have no problems, 10 means I am completely unable to do my usual activities) (optional)

  • Pain/Discomfort

    On a 0-10 scale, how severe is any pain or discomfort you have? - Now (0 means I have no pain or discomfort, 10 means I have extremely severe pain) (optional)
    On a 0-10 scale, how severe is any pain or discomfort you have? - Pre COVID (0 means I have no pain or discomfort, 10 means I have extremely severe pain) (optional)

  • Cognition

    Since your illness have you had new or worsened difficulty with: Concentrating? (optional)
    Since your illness have you had new or worsened difficulty with: Short term memory? (optional)

  • Cognitive-Communication

    Have you or your family noticed any change in the way you communicate with people, such as making sense of things people say to you, putting thoughts into words, difficulty reading or having a conversation? (optional)
    If yes: rate the significance of impact on a scale of 0-10 (0 being no impact, 10 being significant impact) (optional)

  • Anxiety

    On a 0-10 scale, how severe is the anxiety you are experiencing? - Now (0 means I am not anxious, 10 means I have extreme anxious) (optional)
    On a 0-10 scale, how severe is the anxiety you are experiencing? - Pre COVID (0 means I am not anxious, 10 means I have extreme anxious) (optional)

  • Depression

    On a 0-10 scale, how severe is the depression you are experiencing? - Now (0 means I am not depressed, 10 means I have extreme depression) (optional)
    On a 0-10 scale, how severe is the depression you are experiencing? - Pre COVID (0 means I am not depressed, 10 means I have extreme depression) (optional)

  • Global Perceived Health

    How good or bad is your health overall? - Now (0 means the worst health you can imagine, 10 means the best health you can imagine) (optional)
    How good or bad is your health overall? - Pre COVID (0 means the worst health you can imagine, 10 means the best health you can imagine) (optional)

  • Vocation

  • Family/carers views

    Do you think your family or carer would have anything to add from their perspective? (optional)

  • Closing questions:

    Are you experiencing any other new problems since your illness that haven't been mentioned above? (optional)
    Would you be prepared to be contacted for future research? (optional)
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Page last reviewed: 17 January 2025
Page created: 23 August 2022