Underlying Clinical Conditions
Demographics
Record ID:
Family Name:
Given Name:
Middle Name:
Name:
Gender:
...
Male
Female
Date of birth:
Encounter Location:
*
Provider:
*
Provider’s System ID:
*
Date:
*
Any underlying clinical conditions
*
Yes
No
Unknown
Underlying Conditions
Chronic heart disease
*
Yes
No
Unknown
Chronic kidney disease
*
Yes
No
Unknown
Diabetes
*
Yes
No
Unknown
Hypertension
*
Yes
No
Unknown
Immunodeficiency (include HIV)
*
Yes
No
Unknown
Chronic neurological disease
*
Yes
No
Unknown
Chronic respiratory disease
*
Yes
No
Unknown
Asthma requiring medication
*
Yes
No
Unknown
Chronic liver disease
*
Yes
No
Unknown
BMI > 40
*
Yes
No
Unknown
Malignancy
*
Yes
No
Unknown
Pregnant
*
Yes
No
Unknown
Postpartum < 6 weeks
*
Yes
No
Unknown
What is the current pregnancy trimester
*
First
Second
Third
Other comorbidities, please specify:
*
Location of contact with case
Healthcare setting
*
Yes
No
Unknown
Household
*
Yes
No
Unknown
Workplace
*
Yes
No
Unknown
Educational setting
*
Yes
No
Unknown
Traveling with others
*
Yes
No
Unknown
Other
*
Yes
No
Unknown
Other, please specify:
*