antiviral_cmyn |
MEDICATION: While hospitalised or at discharge, were any of the following administered? |
radio |
Antiviral agent? |
1, Yes ; 2, No ; 3, N/A |
antiviral_cmtrt |
|
checkbox |
IF YES to antiviral agent |
1, antiviral_cmtrt___1 Ribavirin ; 2, antiviral_cmtrt___2 Lopinavir/Ritonvir ; 3, antiviral_cmtrt___3 Interferon alpha ; 4, antiviral_cmtrt___4 Interferon beta ; 7, antiviral_cmtrt___7 Chloroquine / Hydroxychloroquine ; 10, antiviral_cmtrt___10 Oseltamivir (Tamiflu) ; 11, antiviral_cmtrt___11 Zanamivir ; 8, antiviral_cmtrt___8 Remdesivir ; 9, antiviral_cmtrt___9 IL6 inhibitor ; 5, antiviral_cmtrt___5 Neuraminidase inhibitors ; 6, antiviral_cmtrt___6 Other or novel antiviral |
remdes_cmtrt_first |
|
text (date_dmy) |
If YES to Remdesivir: |
|
remdes_cmtrt_last |
|
text (date_dmy) |
If YES to Remdesivir: last dose |
|
il6_cmtrt |
|
dropdown |
If YES to IL6 inhibitor: which |
1, Tocilizumab ; 2, Anakinra ; 3, drug X ; 10, Other IL6 inhibitor |
il6_cmtrt_other |
|
text |
Specify other IL6 inhibitor: |
|
il6_cmtrt_first |
|
text (date_dmy) |
If YES to IL6 inhibitor: first dose |
|
il6_cmtrt_last |
|
text (date_dmy) |
If YES to IL6 inhibitor: last dose |
|
neuro_cmtrt |
|
text |
If 'Neuraminidase inhibitors'; Specify which |
|
othantiviral_cmtrt |
|
text |
If 'Other' antiviral agent; Specify type |
|
othantiviral2_cmyn |
|
yesno |
Would you like to add another antiviral? |
1, Yes ; 0, No |
othhantiviral2_cmtrt |
|
text |
If 'Other' antiviral agent; Specify type |
|
othantiviral3_cmyn |
|
yesno |
Would you like to add another antiviral? |
1, Yes ; 0, No |
othantiviral3_cmtrt |
|
text |
If 'Other' antiviral agent; Specify type |
|
othantiviral4_cmyn |
|
yesno |
Would you like to add another antiviral? |
1, Yes ; 0, No |
othantiviral4_cmtrt |
|
text |
If 'Other' antiviral agent; Specify type |
|
othantiviral5_cmyn |
|
yesno |
Would you like to add another antiviral? |
1, Yes ; 0, No |
othantiviral5_cmtrt |
|
text |
If 'Other' antiviral agent; Specify type |
|
antibiotic_cmyn |
|
radio |
Antibiotic agent? |
1, Yes ; 2, No ; 3, N/A |
antibiotic_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic2_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic2_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic3_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic3_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic4_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic4_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic5_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic5_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic6_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic6_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
antibiotic7_cmyn |
|
radio |
Would you like to add another antibiotic? |
1, Yes ; 2, No ; 3, N/A |
antibiotic7_cmtrt |
|
text |
IF YES to antibiotic agent; Specify type |
|
corticost_cmyn |
|
radio |
Corticosteroid agent? |
1, Yes ; 2, No ; 3, N/A |
corticost_cmtrt_type |
|
dropdown |
If YES to Corticosteroid, please confirm type: |
1, Methylprednisolone ; 2, Prednisolone ; 88, Other |
corticost_cmtrt |
|
text |
If YES to Corticosteroid, specify type/name or details of 'Other' corticosteroid: |
|
corticost_cmroute |
|
dropdown |
If YES to Corticosteroid, specify Route |
1, Oral ; 2, Intravenous ; 3, Inhaled |
corticost_cmdose |
|
text |
If YES to Corticosteroid, specify dose |
|
corticost2_cmyn |
|
radio |
Would you like to add another Corticosteroid agent? |
1, Yes ; 2, No ; 3, N/A |
corticost2_cmtrt_type |
|
dropdown |
If YES to Corticosteroid, please confirm type: |
1, Methylprednisolone ; 2, Prednisolone ; 88, Other |
corticost2_cmtrt |
|
text |
If YES to Corticosteroid, specify type/name or details of 'Other' corticosteroid: |
|
corticost2_cmroute |
|
dropdown |
If YES to Corticosteroid, specify Route |
1, Oral ; 2, Intravenous ; 3, Inhaled |
corticost2_cmdose |
|
text |
If YES to Corticosteroid, specify dose |
|
corticost3_cmyn |
|
radio |
Would you like to add another Corticosteroid agent? |
1, Yes ; 2, No ; 3, N/A |
corticost3_cmtrt_type |
|
dropdown |
If YES to Corticosteroid, please confirm type: |
1, Methylprednisolone ; 2, Prednisolone ; 88, Other |
corticost3_cmtrt |
|
text |
If YES to Corticosteroid, specify type/name or details of 'Other' corticosteroid: |
|
corticost3_cmroute |
|
dropdown |
If YES to Corticosteroid, specify Route |
1, Oral ; 2, Intravenous ; 3, Inhaled |
corticost3_cmdose |
|
text |
If YES to Corticosteroid, specify dose |
|
dexamethasone |
|
radio |
Dexamethasone 6mg once per day? |
1, Yes ; 2, No ; 3, N/K ; 4, Yes to Dexamethasone but other dose ; 5, Yes to Dexamethasone but other frequency ; 6, Yes to Dexamethasone but other dose AND other frequency |
dexamethasone_days |
|
text |
Dexamethasone, for how many days |
|
dexamethasone_dose |
|
text |
Dexamethasone Dose in milligrams (mg) |
|
dexamethasone_freq |
|
dropdown |
Dexamethasone Frequency |
1, q.d - once a day ; 2, b.i.d - twice a day ; 3, t.i.d - three times a day ; 4, q.i.d - four times a day ; 5, q.h.s - before bed ; 6, 5X a day ; 7, q.4h - every four hours ; 8, q.6h - every six hours ; 9, q.o.d - every other day ; 10, prn - as needed ; 11, Other frequency ; 99, Unknown |
dexamethasone_other_freq |
|
text |
Dexamethasone, specify Other frequency |
|
dexamethasone_route |
|
dropdown |
If Yes to Dexamethasone, specify Route: |
1, Oral ; 2, Intravenous |
dexamethasone2 |
|
radio |
Second dose of Dexamethasone given? |
1, Yes ; 2, No ; 3, N/A |
dexamethasone2_dose |
|
text |
Dexamethasone 2 Dose in milligrams (mg) |
|
dexamethasone2_freq |
|
dropdown |
Dexamethasone 2 Frequency |
1, q.d - once a day ; 2, b.i.d - twice a day ; 3, t.i.d - three times a day ; 4, q.i.d - four times a day ; 5, q.h.s - before bed ; 6, 5X a day ; 7, q.4h - every four hours ; 8, q.6h - every six hours ; 9, q.o.d - every other day ; 10, prn - as needed ; 11, Other frequency ; 99, Unknown |
dexamethasone2_other_freq |
|
text |
Dexamethasone 2, specify Other frequency |
|
dexamethasone2_route |
|
dropdown |
Dexamethasone 2 Route: |
1, Oral ; 2, Intravenous |
dexamethasone2_days |
|
text |
Dexamethasone 2, number of days given |
|
dexamethasone3 |
|
radio |
Third dose of Dexamethasone given? |
1, Yes ; 2, No ; 3, N/A |
dexamethasone3_dose |
|
text |
Dexamethasone 3 Dose in milligrams (mg) |
|
dexamethasone3_freq |
|
dropdown |
Dexamethasone 3 Frequency |
1, q.d - once a day ; 2, b.i.d - twice a day ; 3, t.i.d - three times a day ; 4, q.i.d - four times a day ; 5, q.h.s - before bed ; 6, 5X a day ; 7, q.4h - every four hours ; 8, q.6h - every six hours ; 9, q.o.d - every other day ; 10, prn - as needed ; 11, Other frequency ; 99, Unknown |
dexamethasone3_other_freq |
|
text |
Dexamethasone 3, specify Other frequency |
|
dexamethasone3_route |
|
dropdown |
Dexamethasone 3 Route: |
1, Oral ; 2, Intravenous |
dexamethasone3_days |
|
text |
Dexamethasone 3, number of days given |
|
dexamethasone4 |
|
radio |
Fourth dose of Dexamethasone given? |
1, Yes ; 2, No ; 3, N/A |
dexamethasone4_dose |
|
text |
Dexamethasone 4 Dose in milligrams (mg) |
|
dexamethasone4_freq |
|
dropdown |
Dexamethasone 4 Frequency |
1, q.d - once a day ; 2, b.i.d - twice a day ; 3, t.i.d - three times a day ; 4, q.i.d - four times a day ; 5, q.h.s - before bed ; 6, 5X a day ; 7, q.4h - every four hours ; 8, q.6h - every six hours ; 9, q.o.d - every other day ; 10, prn - as needed ; 11, Other frequency ; 99, Unknown |
dexamethasone4_other_freq |
|
text |
Dexamethasone 4, specify Other frequency |
|
dexamethasone4_route |
|
dropdown |
Dexamethasone 4 Route: |
1, Oral ; 2, Intravenous |
dexamethasone4_days |
|
text |
Dexamethasone 4, number of days given |
|
dexamethasone5 |
|
radio |
Fifth dose of Dexamethasone given? |
1, Yes ; 2, No ; 3, N/A |
dexamethasone5_dose |
|
text |
Dexamethasone 5 Dose in milligrams (mg) |
|
dexamethasone5_freq |
|
dropdown |
Dexamethasone 5 Frequency |
1, q.d - once a day ; 2, b.i.d - twice a day ; 3, t.i.d - three times a day ; 4, q.i.d - four times a day ; 5, q.h.s - before bed ; 6, 5X a day ; 7, q.4h - every four hours ; 8, q.6h - every six hours ; 9, q.o.d - every other day ; 10, prn - as needed ; 11, Other frequency ; 99, Unknown |
dexamethasone5_other_freq |
|
text |
Dexamethasone 5, specify Other frequency |
|
dexamethasone5_route |
|
dropdown |
Dexamethasone 5 Route: |
1, Oral ; 2, Intravenous |
dexamethasone5_days |
|
text |
Dexamethasone 5, number of days given |
|
antifung_cmyn |
|
radio |
Antifungal agent? |
1, Yes ; 2, No ; 3, N/A |
antifungal_cmtrt |
|
text |
IF YES to antifungal agent; Specify which |
|
offlabel_cmyn |
|
radio |
Off-label / Compassionate Use medications? |
1, Yes ; 2, No ; 3, N/K |
offlabel_cmtrt |
|
text |
IF YES to Off-label / Compassionate Use medications; Specifywhich |
|
interleukin_cmyn |
|
radio |
Interleukin inhibitors |
1, Yes ; 2, No ; 3, N/K |
interleukin_cmtrt |
|
text |
IF YES to Interleukin inhibitors; Specify which |
|
conv_plasma_cmyn |
|
radio |
Convalescent plasma |
1, Yes ; 2, No ; 3, N/K |
icu_hoterm |
TREATMENT: At ANY time during hospitalisation, did the patient receive/undergo: |
dropdown |
ICU or High Dependency admission |
1, Yes ; 2, No ; 3, N/A |
icu_no |
|
radio |
If No to ICU or High Dependency Unit admission: |
1, Not indicated ; 2, Not appropriate |
icu_hostdat |
|
text (date_dmy) |
Date of ICU/HDU admission: |
|
icu_hostdatnk |
|
radio |
Date of ICU/HDU admission N/K |
1, N/K |
icu_hoendat |
|
text (date_dmy) |
Date of ICU/HDU admission N/K |
|
icu_hoendatnk |
|
radio |
Date of discharge N/K |
1, N/K |
icu_hostdat2 |
|
text (date_dmy) |
Date of ICU/HDU admission 2: |
|
icu_hostdat2_nk |
|
radio |
Date of ICU/HDU admission 2 N/K |
1, N/K |
icu_hoendat2 |
|
text (date_dmy) |
Date of ICU/HDU discharge 2 |
|
icu_hoendat2_nk |
|
radio |
Date of ICU/HDU discharge 2 N/K |
1, N/K |
icu_hostdat3 |
|
text (date_dmy) |
Date of ICU/HDU admission 3: |
|
icu_hostdat3_nk |
|
radio |
Date of ICU/HDU admission 3 N/K |
1, N/K |
icu_hoendat3 |
|
text (date_dmy) |
Date of ICU/HDU discharge 3: |
|
icu_hoendat3_nk |
|
radio |
Date of ICU/HDU discharge 3 N/K |
1, N/K |
icu_hostillin |
|
radio |
Still in ICU/HDU |
1, Yes |
hodur |
|
text |
If YES, total duration (days) |
|
oxygen_cmoccur |
At ANY time during hospitalisation, did the patient receive/undergo |
radio |
Oxygen therapy |
1, Yes ; 2, No ; 3, N/A |
oxygenhf_cmoccur |
|
radio |
High-flow nasal canula? |
1, Yes ; 2, No ; 3, N/A |
noninvasive_proccur |
|
radio |
Non-invasive ventilation ? (e.g. BIPAP, CPAP) |
1, Yes ; 2, No ; 3, N/A |
invasive_proccur |
|
radio |
Invasive ventilation (Any intubation) ? |
1, Yes ; 2, No ; 3, N/A |
pronevent_prtrt |
|
radio |
Prone ventilation |
1, Yes ; 2, No ; 3, N/A |
inhalednit_cmtrt |
|
radio |
Inhaled Nitric Oxide |
1, Yes ; 2, No ; 3, N/A |
tracheo_prtrt |
|
radio |
Tracheostomy inserted |
1, Yes ; 2, No ; 3, N/A |
extracorp_prtrt |
|
radio |
Extracorporeal (ECMO) support |
1, Yes ; 2, No ; 3, N/A |
rrt_prtrt |
|
radio |
Renal replacement therapy (RRT) or dialysis |
1, Yes ; 2, No ; 3, N/A |
inotrop_cmtrt |
|
radio |
Inotropes / vasopressors |
1, Yes ; 2, No ; 3, N/A |
invasive_prdur |
|
text |
If yes to Invasive ventilation; confirm duration (days) |
|
invasive_still_on |
|
radio |
If yes to Invasive ventilation - still on it |
1, still on |
excorp_prdur |
|
text |
If YES to Extracorporeal (ECMO) support; confirm duration (days) |
|
excorp_still_on |
|
radio |
If yes to Extracorporeal (ECMO) support - still on it |
1, still on |
rrt_totdur |
|
text |
If YES to RRT or dialysis, total duration (days) |
|
rrt_still_on |
|
radio |
If YES to RRT or dialysis - still on it |
1, still on |
inotrope_cmdur |
|
text |
If YES to Inotropes/vasopressors; confirm duration (days) |
|
inotrope_still_on |
|
radio |
If YES to Inotropes/vasopressors - still on them |
1, still on |
other_cmyn |
|
radio |
OTHER intervention or procedure |
1, Yes ; 2, No ; 3, N/A |
other_cm |
|
text |
IF YES OTHER intervention or procedure; Specify (Write 'N/A' for no additional procedure) |
|
bloodgroup |
|
radio |
Blood Group (please check past as well as current medical record) |
1, A ; 2, B ; 3, AB ; 4, O ; 9, N/K |
treatment_complete |
Form Status |
dropdown |
Treatment section complete? |
0, Incomplete ; 1, Unverified ; 2, Complete |