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For A-T Providers

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For Providers

Name of clinician
First Last
Clinician email
Patient Information
Date of Birth
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
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
Date of 2nd dose of vaccine (if applicable)
Date of COVID-19 diagnosis
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

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