Please indicate whether you have been affected by any of the following as a result of COVID-19.	Decreased	No Change	Increased	Not Applicable
Ability to access mental/behavioral health care	□	□	□	□
Ability to access physical health care	□	□	□	□
Alcohol consumption	□	□	□	□
Anger	□	□	□	□
Anxiety	□	□	□	□
Exercise	□	□	□	□
Faith in your belief system (e.g., Christianity, spirituality)	□	□	□	□
Fear of having a seizure (if applicable)	□	□	□	□
Fear of care recipient having a seizure (if applicable)	□	□	□	□
Fear of seeking healthcare (physical or mental/behavioral) when you needed it	□	□	□	□
Hobbies	□	□	□	□
Meditation	□	□	□	□
Refilling prescription medications	□	□	□	□
Sense of control over your life	□	□	□	□
Sense of social isolation	□	□	□	□
Smoking	□	□	□	□
Stress	□	□	□	□
Symptoms of pre-existing or current health conditions	□	□	□	□
Time spent outside	□	□	□	□
Use of healthcare	□	□	□	□
Use of mental/behavioral health care	□	□	□	□