sex |
DEMOGRAPHICS |
radio |
Sex at birth |
1, Male ; 2, Female ; 3, Not specified |
agedatyn |
|
yesno |
Birth date known |
1, Yes ; 0, No |
agedat |
|
text (date_dmy) |
Birth date |
|
calc_age |
|
calc |
Calculated age (comparing DOB with DOE) - inaccurate with 29th Feb Dates |
rounddown(datediff([agedat], [dsstdat], "y", "dmy", true)) |
age_estimateyears |
|
text |
Age/estimated age |
|
age_estimateyearsu |
|
dropdown |
Age/estimated age unit |
1, Months ; 2, Years |
postcode |
|
text |
Postcode |
|
nhs_chi |
|
text |
England/Wales NHS number, Scotland CHI number |
|
ethnic |
|
checkbox |
Ethnic Group (check all that apply) |
1, ethnic___1 Arab ; 2, ethnic___2 Black ; 3, ethnic___3 East Asian ; 4, ethnic___4 South Asian ; 5, ethnic___5 West Asian ; 6, ethnic___6 Latin American ; 7, ethnic___7 White ; 8, ethnic___8 Aboriginal/First Nations ; 9, ethnic___9 Other ; 10, ethnic___10 N/A |
other_ethnic |
|
text |
Specified "Other" ethnic group |
|
healthwork_erterm |
|
dropdown |
Employed as healthcare worker |
1, Yes ; 2, No ; 3, N/A |
labwork_erterm |
|
dropdown |
Employed in microbiology laboratory |
1, Yes ; 2, No ; 3, N/A |
pregyn_rptestcd |
|
radio |
Pregnant |
1, Yes ; 0, No ; 998, Unknown ; 999, N/A |
egestage_rptestcd |
|
text |
If pregnant, gestational weeks assessment |
|
postpart_rptestcd |
|
radio |
Post partum (within 6 weeks) |
1, Yes ; 0, No ; 3, N/K |
pregout_rptestcd |
|
radio |
Pregnancy Outcome |
1, Live birth ; 2, Still birth |
dlvrdtc_rptestcd |
|
text (date_dmy) |
Delivery date |
|
aplb_lbperf |
|
radio |
Baby tested for mothers ARI infection |
1, Yes ; 2, No ; 3, N/A |
aplb_lborres |
|
radio |
Baby test result |
1, Positive ; 2, Negative |
aplb_lbmethod |
|
radio |
Baby test methodology |
1, PCR ; 2, Other |
aplb_lbmethodoth |
|
text |
If other, specify test methodology |
|
apdm_age |
|
yesno |
Infant - less than 1 year old? |
1, Yes ; 0, No |
apvs_weight |
|
text |
Birth weight if known |
|
apvs_weightu |
|
dropdown |
Birth weight unit |
1, kg ; 2, lbs |
apvs_weightnk |
|
dropdown |
Birth weight not known |
1, N/K |
apsc_gestout |
|
radio |
Gestational outcome |
1, Term birth ( >= 37wk GA) ; 2, Preterm birth (< 37wk GA) ; 3, N/A |
estgest |
|
text |
If preterm birth, estimated gestation period |
|
apsc_brfedind |
|
radio |
Breastfed |
1, Yes ; 2, No ; 3, N/A |
apsc_brfedindy |
|
radio |
If breastfed, current status |
1, Currently breastfed ; 2, Breastfeeding discontinued ; 3, N/A |
apsc_brdisdat |
|
text |
If breastfeeding discontinued, at how many weeks |
|
apsc_dvageind |
|
dropdown |
Appropriate development for age? |
1, Yes ; 2, No ; 3, N/A |
apsc_vcageind |
|
dropdown |
Vaccinations appropriate for age/country? |
1, Yes ; 2, No ; 3, Unknown ; 4, N/A |
covid19_vaccine |
VACCINATION STATUS |
dropdown |
Has the patient received a COVID-19 vaccine? |
1, Yes ; 0, No ; 3, N/K |
covid19_vaccined |
|
text (date_dmy) |
COVID-19 first dose vaccine date if known |
|
covid19_vaccined_nk |
|
radio |
If first dose vaccine date not known |
1, N/K |
covid19_vaccine2d |
|
text (date_dmy) |
COVID-19 second dose vaccine date if known |
|
covid19_vaccine2d_nk |
|
radio |
If second dose vaccine date not known |
1, N/K |
covid19_vaccine_type |
|
dropdown |
Vaccine type/Manufacturer |
1, Pfizer-BioNTECH ; 2, Oxford-AstraZeneca ; 3, Moderna ; 88, Other ; 99, N/K |
covid19_vaccine_other_type |
|
text |
If "Other" vaccine type, specified here |
|
vaccine_covid_trial |
|
dropdown |
Patient previously involved in COVID vaccine trial? |
1, Yes ; 0, No ; 3, N/K |
vaccine_covid_triald |
|
text (date_dmy) |
Date of first trial vaccination if known |
|
influenza_2021_vaccine |
|
dropdown |
Patient received a 2020/21 seasonal influenza vaccine? |
1, Yes ; 0, No ; 3, N/K |
influenza_2021_vaccined |
|
text (date_dmy) |
Date of 2020/21 seasonal influenza vaccine if known |
|
influenza_2021_vaccined_nk |
|
radio |
Date of 2020/21 seasonal influenza vaccine not known |
1, N/K |
demographics_complete |
Form Status |
dropdown |
Demographics section complete? |
0, Incomplete ; 1, Unverified ; 2, Complete |