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Name of clinician
First
Last
Clinician email
Patient Information
Date of Birth
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Biological Sex
Male
Female
Weight (lbs)
BMI
Type of A-T
Classic/Typical
Mild/Variant
Prior to COVID Infection
Previous history of:
Pneumonia
Chronic lung disease
Exposure to tobacco smoke
Respiratory medications (e.g. brochodilators, therapy vest, cough assist)
Swallowing difficulties
Gastrostomy/feeding tube
Cancer diagnosis (previous or current)
Chronic conditions (e.g. diabetes, metabolic syndrome, granulomas, etc.)
History of hospitalizations
If yes to any of the above, please specify.
For history of hospitalizations, provide diagnosis and information about hospital course.
Medications prior to COVID infection:
Immunoglobulin therapy (IV or subcutaneous)
Prophylactic antibiotic
Current or recent chemotherapy
Current or recent corticosteroids
If yes to any of the above, please specify.
Date of most recent lab prior to COVID infection
Month
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White blood cell count from most recent lab prior to COVID infection
Neutrophil count from most recent lab prior to COVID infection
Lymphocyte count from most recent lab prior to COVID infection
CD4 count from most recent lab prior to COVID infection
IgG from most recent lab prior to COVID infection
IgA from most recent lab prior to COVID infection
IgM from most recent lab prior to COVID infection
During COVID Infection
Source of infection (if known)
Please list symptoms
Length of time symptoms were present prior to COVID testing
Prior immunization with COVID vaccine
Yes
No
If yes, which vaccine did the patient receive?
Moderna
Pfizer
Johnson & Johnson
Date of 1st dose of vaccine
Month
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Date of 2nd dose of vaccine (if applicable)
Month
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Date of COVID-19 diagnosis
Month
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Day
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1920
White blood count at diagnosis
Lymphocyte count at diagnosis
White blood counts (list all obtained)
Lowest white blood count
Lowest lymphocyte count
Description of chest CT scan (if applicable)
Serum samples saved from patient
Yes
No
Levels of inflammatory cytokines (e.g. IL-6)
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30628-0/fulltext
Patient was treated with
Convalescent plasma
Monoclonal antibody
Remdesivir
Corticosteroids
Other
If other treatment, please specify.
Patient required hospitalization
Yes
No
If yes, please specify number of days in hospital and number of days in intensive/critical care.
Patient required
Oxygen by nasal canula or facemask
Intubation
ECMO
None of the above
Severity of the infection in the patient
Chronic COVID infection (repetitive positive COVID PCR)
Recurrent COVID infection after recovery of initial infection
Patient died from COVID infection
None of the above
Post COVID Infection (at time of discharge)
Patient's oral feeding routine declined
Yes
No
Patient's neurologic function declined
Yes
No
Not assessed
Patient's pulmonary function declined
Yes
No
Not assessed
Other sequelae of infection
Yes
No
If yes, please specify.
Patient was discharged to his/her home
Yes
No
If no, please specify.
Parent or caregiver level of concern/worry at time of discharge
Very concerned/worried
Somewhat concerned/worried
Not at all concerned/worried