Brain Fog Data Assessment Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeDate & Time of this Incident ReportOxygen Saturation Selected Value: 10 Please use a pulse oximeter to record your percent oxygen saturation during this episode. Normal Range is between 80-100. Healthy Range is above 95. You can purchase an excellent oximeter at our store or use your own personal mobile measuring device. Blood Pressure: DiastolicPlease enter your resting diastolic blood pressure. Normal value is 80Blood Pressure: SystolicPlease enter your resting systolic blood pressure. Normal value is 120.Level of Confusion PresentRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate your current level of fatigue?Level of Disability Due to Brain FogRate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10, 10 being worst, how would you rate your ability to function?Characterize Your Level of ConfusionExtreme-DebilitatingMust SleepComes & GoesMinorPlease select all that applyThis Episode is:Increasing SignificantlyIncreasing SomewhatHolding SteadyDecreasing SomewhatResolvedHow would you describe this incident against others you have experienced.Are You Aware of Any of The Following?Problem ConcentratingNegative ThoughtsAngerMemory ProblemHeadacheLoss of ConsciousnessNeed to SleepPlease select all that applyHow Did This Incident OnsetSuddenlyGradually IncreasedFluctuatesConstant-SteadyAfter ExerciseAfter Mental ActivityAfter SleepAfter WorkAfter EatingWhile RestingHow would you describe this incident against others you have experienced.Does Anything Relieve the Fog?YesNoAlcoholMealMedicationOxygenSleepIs there anything that you can do to reduce the fatigue from COVID-19?Do Any of These Accompany This Episode of Your COVID-19 Brain Fog?DepressionAbdominal PainAnxietyAnemiaBruisingChest PainConstipationCold IntoleranceCyanosis-Bluing of fingers, etc.Dizziness-FallsEdema-SwellingHemorrhagesLow-back PainNeurosisSkin ChangesTension-stateTrouble BreathingTrouble SwallowingArrhythmiasWoozinessConfusionVision & Eye ProblemsTinnitus-Ringing Ears Weight GainWeight LossPlease select all that applySubmit