Monoclonal Antibody - Symptoms Survey

Pre- MAB MAB MAB MAB MAB W

MAB - Day week Week Week Week k
1 1 2 3 4 8

Date

Over the past 7 days, how much diffi-

culty have you had with the following:

Standing for long periods such as 30

minutes?

Taking care of your household respon-

sibilities?

Learning a new task, e.g. learning how

to get to a new place?

Joining in community activities (e.g.

festivities, religious, other)?

Being emotionally affected by your

health problems?
Concentrating on doing something for
ten minutes?
Walking a long distance such as a kilo-
metre (or equivalent)?
Washing your whole body?

Getting dressed?

Dealing with people you do not know?

Maintaining a friendship?

Your day-to-day work/school?

Tremors / Fasciculations

Nerve Pain

Parasthesias
 Internal Tremors

Total Score

Score:
0 No Difficulty
1 Mild Difficulty
2 Moderate Difficulty
3 Severe Difficulty
4 Extreme Difficulty or Cannot do

Did you receive your Monoclonal Antibodies due to an active covid infection? ____Yes. ___No
Have you had prior Covid infection? Are you a Long-hauler? ___Yes ___No
Have you had Covid Vaccination? ____Yes ____No
Did your Vaccine affect your symptoms? ____ Yes ____ No

Please Email your filled out form 4 weeks post infusion to: react19org@gmail.com
Please send a followup at 2 months, and another at 3 months.

*** PRIVACY POLICY ***

REACT 19 Foundation - Research, Education, Action, for Covid Therapeutics
A grassroots organization focused on patient-led research to increase our understanding on the lasting effects and
possible treatments for long-haulers, and a small subset who are experiencing issues after the Covid Vaccines.

REACT19 DOES NOT endorse or encourage the use of any therapeutics. This organization will collect data on vari-
ous treatment methods.

ALL identifying information will be kept completely confidential, this personal information will be omitted from any re-
ports made from the collected survey data. These reports will then be used to collaborate with researchers, research
institutions, and patients.