Who is completing this form?

Please think about your current level of well-being. When you think about well-being, think about your physical health, your emotional health, any challenges you are experiencing, the people in your life, and the opportunities or resources you have available to you. How would you describe your current level of well-being?

Has your living arrangement, including the place where you live and the people that live with you, changed since March 2020 due to the COVID-19 pandemic?

Living arrangement: What has changed? Mark all that apply. I moved to live with other family members or friends.

Living arrangement: What has changed? Mark all that apply. Other family or friends moved in with me.

Living arrangement: What has changed? Mark all that apply. Some household members moved away to limit the possibility of infection.

Living arrangement: What has changed? Mark all that apply. I moved out of shared housing to limit the possibility of infection.

Living arrangement: What has changed? Mark all that apply. A care provider/companion now comes to help me.

Living arrangement: What has changed? Mark all that apply. My care provider/companion no longer comes to help me.

Living arrangement: What has changed? Mark all that apply. I have moved into a care facility.

Living arrangement: What has changed? Mark all that apply. I have moved out of a care facility.

Living arrangement: What has changed? Mark all that apply. Other.

Including yourself, how many people live in the same household with you?

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. Does not apply. I live in a private home.

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. Residents are not allowed to leave their home/apartment/room.

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. Residents are not allowed to have visitors.

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. Residents are not allowed to leave the property except for emergencies.

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. Food is delivered to the home/apartment/room.

Are any of the services and/or restrictions below part of where you currently live as a result of the COVID-19 pandemic? Mark all that apply. There are no restrictions on residents.

Do you have any close family members living in an assisted living, skilled nursing, or nursing home?

Are you able to visit them in their care facility?

To your knowledge, have you EVER been exposed to another person who has been diagnosed with, or suspected of having, COVID-19 infection?

Has anyone in your family or a close friend died from COVID-19?

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Fever.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Persistent cough.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Chills or sweats.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Headache.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Sore throat.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Unusually hoarse.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Loss of smell.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Loss of taste.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Chest pain/tightness.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Muscle aches.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Abdominal pain.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Diarrhea.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Confusion.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Malaise-a general feeling of illness, discomfort, uneasiness.

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Unusual fatigue.

Unusual fatigue: How severe was this symptom?

Below is a list of symptoms that may be related to COVID-19. Some of these may also occur with other conditions such as allergies, colds and flu or when taking certain medications. Please indicate if you have experienced any of these symptoms for longer than several hours or more than is usual for you, since March 2020. Mark all that apply. Unusual shortness of breath or difficulty breathing.

Unusual shortness of breath or difficulty breathing: How severe was this symptom?

Which of the following statements apply to you?

Have you been tested for COVID-19?

What kind of test(s) did you have? Mark all that apply. Nasal swab (testing for presence of the virus).

What kind of test(s) did you have? Mark all that apply. Throat swab (testing for presence of the virus).

What kind of test(s) did you have? Mark all that apply. Saliva test (testing for presence of the virus).

What kind of test(s) did you have? Mark all that apply. Blood test (testing for antibodies/immune response).

How many times have you been tested?

Did any of these tests come back positive for a COVID-19 infection?

Which test(s) came back positive?

Which test(s) came back positive?

Which test(s) came back positive?

Which test(s) came back positive?

Were you ever hospitalized for COVID-19?

How many nights did you stay in the hospital?

What treatments did you receive? Mark all that apply. Intravenous fluids.

What treatments did you receive? Mark all that apply. Oxygen through nasal (nose) prongs or facial mask, but not requiring a ventilator.

What treatments did you receive? Mark all that apply. Invasive ventilation or ventilator (Breathing support through an inserted tube. People are usually asleep for this procedure.)

What treatments did you receive? Mark all that apply. Kidney dialysis.

What treatments did you receive? Mark all that apply. Cardiac or heart procedure, such as a coronary artery stent.

What treatments did you receive? Mark all that apply. Other.

Did you require treatment in an Intensive Care Unit (ICU)?

ICU: How many days?

Were you given any of the following medications to treat COVID-19? Mark all that apply. Remdesivir.

Were you given any of the following medications to treat COVID-19? Mark all that apply. Hydroxychloroquine or chloroquine.

Were you given any of the following medications to treat COVID-19? Mark all that apply. Azithromycin.

Are you currently taking any prescription medications not related to COVID-19?

Are you taking prescription medications for any of the following conditions? Mark all that apply. High blood pressure.

High blood pressure medications: Beta-Blockers (Examples: Atenolol, Metoprolol, Carvedilol)

High blood pressure medications: Calcium channel blockers (Examples: Amlodipine, Diltiazem)

High blood pressure medications: Thiazide Diuretics (Examples: Hydrochlorothiazide, Chlorthalidone, Moduretic, Dyazide, Indapamide)

High blood pressure medications: Loop Diuretics (Examples: Furosemide, Lasix, Torsemide, Bumex, Ethacrynic acid)

High blood pressure medications: ACE-Inhibitors (Examples: Lisinopril, Enalapril, Ramipril, Captopril, Benazepril)

High blood pressure medications: Angiotensin receptor blockers (Examples: Valsartan, Irbesartan, Entresto, Losartan, Candesartan, Olmesartan)

High blood pressure medications: Aldosterone Receptor Blockers Examples: Spironolactone, Eplerenone)

High blood pressure medications: Alph-Blockers (Examples: Terazosin, Doxazosin)

High blood pressure medications: Other

Are you taking medications for any of the following conditions? Mark all that apply. Diabetes.

Diabetes medications: Insulin injections.

Diabetes medications: SGLT2 Inhibitors (Jardiance, Invokana, Dapagliflozin)

Diabetes medications: Glucophage (Metformin)

Diabetes medications: Non-Insulin Injections or GLP1 Agonists (Examples: Exenatide, Byetta, Ozempic, Victoza, Trulicity)

Diabetes medications: Sulfonylurea (Examples: Glucotrol (Glipizide), Glimepiride, Chlorpropamide)

Diabetes medications: Other oral medications (Examples: Avandia, Prandin, Januvia, Starlix, Actos)

Diabetes medications: Other diabetes medication(s)

Are you taking prescription medications for any of the following conditions? Mark all that apply. Cancer.

Are you taking prescription medications for any of the following conditions? Mark all that apply. Autoimmune diseases (lupus, rheumatoid arthritis, Crohn's disease).

Are you taking prescription medications for any of the following conditions? Mark all that apply. Other conditions.

How do you get your prescription medications now?

Has the way you get your prescription medications changed since March 2020?

Do you take any over-the-counter pain/anti-inflammatory medications on a routine basis (at least 3 days per week)?

Over the counter pain/anti-inflammatory medications: Which of the following do you take regularly? Aspirin (Examples: Bayer, Bufferin).

Over the counter pain/anti-inflammatory medications: Which of the following do you take regularly? Ibuprofen (Examples: Motrin, Advil).

Over the counter pain/anti-inflammatory medications: Which of the following do you take regularly? Acetaminophen (Example: Tylenol).

Over the counter pain/anti-inflammatory medications: Which of the following do you take regularly? Naproxen (Example: Aleve).

Over the counter pain/anti-inflammatory medications: Which of the following do you take regularly? Other.

Are you experiencing any new difficulties in taking medication(s) since the COVID-19 pandemic started? Mark all that apply. Delays in getting prescripts filled/refilled.

Are you experiencing any new difficulties in taking medication(s) since the COVID-19 pandemic started? Mark all that apply. Delaying or not taking medication.

Are you experiencing any new difficulties in taking medication(s) since the COVID-19 pandemic started? Mark all that apply. No longer having someone to help me take my medications.

Are you experiencing any new difficulties in taking medication(s) since the COVID-19 pandemic started? Mark all that apply. Paying for medications.

Are you experiencing any new difficulties in taking medication(s) since the COVID-19 pandemic started? Mark all that apply. Other.

From March 2020 until now, did you have any health care appointments scheduled?

Did your health care provider cancel, reschedule or convert your appointment to a telephone or online/video visit (telehealth)? Mark all that apply. Yes, at least one was cancelled.

Did your health care provider cancel, reschedule or convert your appointment to a telephone or online/video visit (telehealth)? Mark all that apply. Yes, at least one was rescheduled.

Did your health care provider cancel, reschedule or convert your appointment to a telephone or online/video visit (telehealth)? Mark all that apply. Yes, at least one was converted to telephone or online/video visit.

Did your health care provider cancel, reschedule or convert your appointment to a telephone or online/video visit (telehealth)? Mark all that apply. None of them changed.

Have you decided not to go to the doctor or hospital when you normally would have gone, to avoid the potential of being exposed to COVID-19?

In general, how much difficulty have you had getting routine medical care since March 2020?

In general, how concerned are you about the COVID-19 pandemic?

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. My risk of getting a COVID-19 infection.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. The risk of family members or friends getting a COVID-19 infection.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Getting the health care that I need.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Getting adequate food.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Getting enough exercise/physical activity.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Getting the sleep/rest I need.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Having adequate housing.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. Having enough money to cover my needs.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. My personal safety.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. The health and safety of my family and friends.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. My financial security.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. The financial security of my family.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. My ability to be with friends and family.

Is the COVID-19 pandemic causing you concerns about any of the following? Mark all that apply. The nation and the economy more generally.

How often would the following statements apply to you in the past 7 days... I felt fearful

How often would the following statements apply to you in the past 7 days... I found it hard to focus on anything other than my anxiety

How often would the following statements apply to you in the past 7 days... My worries overwhelmed me

How often would the following statements apply to you in the past 7 days... I felt uneasy

In the past 4 weeks how often have you felt... That you were unable to control the important things in your life?

In the past 4 weeks how often have you felt... confident about your ability to handle your personal problems?

In the past 4 weeks how often have you felt... That things were going your way?

In the past 4 weeks how often have you felt... That difficulties were piling up so high that you could not overcome them?

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Washing hands frequently.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Trying not to touch my face.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Disinfecting surfaces frequently.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Maintaining a physical distance from people outside my household.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Wearing a face mask in public.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Wearing gloves in public

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Avoiding in-person social or religious activities.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Avoiding or limiting in-person shopping.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Avoiding shaking hands.

Since March 2020, what steps have you taken to reduce your risk of being infected by COVID-19? Mark all that apply. Staying home.

How often do you communicate with others who live outside your home?

Compared to the months before the outbreak began, would you say this is...

How are you staying in touch with others who do not live with you? Mark all that apply. Speaking in person.

How are you staying in touch with others who do not live with you? Mark all that apply. By telephone.

How are you staying in touch with others who do not live with you? Mark all that apply. With video calls.

How are you staying in touch with others who do not live with you? Mark all that apply. By email.

How are you staying in touch with others who do not live with you? Mark all that apply. By social media (Examples: Facebook, Instagram).

How are you staying in touch with others who do not live with you? Mark all that apply. By postal mail.

How are you staying in touch with others who do not live with you? Mark all that apply. Other.

In the past 3 months, how many drinks containing alcohol have you had on average?

Do you smoke regular or electronic cigarettes now?

Over the past month, how would you describe your level of physical activity or exercise, compared to your average physical activity level before the COVID-19 pandemic began?

Think about the walking you do outside the home. In the past month, how often haveyou walked outside the home (or done indoor activity equivalent to walking outside, to accumulate steps) for at least 5 minutes without stopping.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Getting food or medicine for others.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Providing childcare.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Donating blood.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Donating money.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Making masks for others

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Contacting friends or family to keep in touch.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. Other.

Which of the following new actions are you taking to help your family, friends or your community during this COVID-19 pandemic? Mark all that apply. I have not taken any new action.

Computed from Form 190, questions 27-30. Source: Four-item version of the Perceived Stress Scale (Cohen 1983). After reverse coding the responses to questions 28 and 29, and subtracting one from each response, the responses to all four items are summed. The scale ranges from 0 to 16, where a higher score indicates more perceived stress.

Computed from Form 190, questions 23-26. Source: Four-item version of the PROMIS Anxiety score (Pilkonis 2011). Responses to all four items are summed to obtain a raw score. The raw score is then referred to a scoring table (PROMIS Anxiety Scoring Manual) to convert the total raw score into a T-score. The scoring table is only valid when participants answer all questions. Scores for participants with missing responses were submitted to the Health Measures Scoring Service (https://www.assessmentcenter.net/ac_scoringservice) to obtain final T-scores.