This questionnaire is for people in Derbyshire that have had either a confirmed diagnosis of coronavirus disease (COVID-19) or have experienced coronavirus symptoms, such as a high temperature, persistent cough, loss of taste and smell.
This questionnaire is to find out if you are continuing to experience diagnosed coronavirus or suspected coronavirus symptoms. We will add any information you provide in your confidential clinical notes, and forward on to the Post (Long) COVID-19 Assessment Service, where Clinicians from different professions will assess you and will work together to ensure you receive the most appropriate care for your symptoms. You may also be referred to other services to provide additional support and treatment for your symptoms.
The information you provide will be stored as per data protection regulations, and used for purposes of clinical assessment only (for use only by Clinicians involved in your care), and will be kept in your patient records.
You can use this service if you:
- are registered at the surgery
Before you start
We’ll ask you for:
- your first and last name, date of birth, sex, postcode, email and phone number
- if applicable, the details of the person you are completing the form on behalf of
You can also phone us on 01663 745266.