Infectious Disease
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approximately 35 views since a bird in the hand was worth two in the bush.
Date of Virtual Assessment: [date name="variable_1" default=""]

DEMOGRAPHICS
Name: [text name="name_1" default=""]
Age: [text name="age_1" default=""]
Sex [checkbox name="sex" value="Female|Male|unknown/prefers not to respond"]
Pregnant: [checkbox name="current pregnancy" value="Y|N|unknown"]
Healthcare Worker (HCW): [checkbox name="HCW" value="Y|N"]

ONSET OF SYMPTOMS
[checkbox name="NoC19ssx" value="No reported symptoms consistent with Covid19"] Symptom onset (date of first symptom) [date name="ssx_onset" default=""]
Have you had a fever? If yes,Date of first fever (>38.0)[date name="fever_onset" default=""]
Date of COVID Test Positive [date name="testpos_date" default=""]

Travel in the 14 days prior to first symptom onset [date name="travelQ" default=""]
If yes, Country?
[text name="country" default=""]
City/Geographic Area: [text name="citygeo" default=""]
Did you have a known/identified COVID Exposure?
[checkbox name="expQ" value="Y|N"]
If yes: Date of Exposure: [date name="expdate" default=""]
Location of Exposure:
[date name="ex_site" default=""]

PAST MEDICAL HISTORY/CO-MORBIDITIES
[checkbox name="NoSigHx" value="No significant Past Medical History or Co-morbidities"]
Cardiac disease [checkbox name="CardsHx" value="Y|N"]
Chronic lung Disease [checkbox name="LungHx" value="Y|N"]
Asthma [checkbox name="AsthmaHx" value="Y|N"]
Smoker [checkbox name="TobHx" value="Y|N"]
Chronic kidney disease [checkbox name="CKDHx" value="Y|N"]
Moderate or severe liver
disease [checkbox name="LivHx" value="Y|N"]
Chronic neurological issues [checkbox name="NeuroHx" value="Y|N"]
Malignancy [checkbox name="CancerHx" value="Y|N"]
Chronic hematologic disease [checkbox name="HemeHx" value="Y|N"]
HIV [checkbox name="HIVHx" value="Y|N"]
Diabetes [checkbox name="DMHx" value="Y|N"]
Hypertension [checkbox name="HTNHx" value="Y|N"]
Rheumatic disorder [checkbox name="RheumHx" value="Y|N"]

Notes:
[textarea name="PMhxNotes" default=""]

CURRENT SYMPTOMS
Fever [checkbox name="Fever" value="Y|N"]
Sore Throat [checkbox name="ST" value="Y|N"]
Runny Nose [checkbox name="Rhino" value="Y|N"]
Cough [checkbox name="Cough" value="Y|N"]
Are you short of breath? [checkbox name="SOB" value="Y|N"]
Are you breathing harder or faster
when doing nothing at all? [checkbox name="SOB at rest" value="Y|N"]
Are you breathing faster than normal? [checkbox name="WOB" value="Y|N"]
Does anything make you breathless today
that didn’t make you breathless
yesterday? [checkbox name="Change in Breathing" value="Y|N"]
Chills/Rigors [checkbox name="Chills/Rigors" value="Y|N"]
Conjunctivitis [checkbox name="Conjunctivitis" value="Y|N"]
Ear Pain [checkbox name="Ear Pain" value="Y|N"]
Anosmia [checkbox name="Anosmis" value="Y|N"]
Dysgeusia [checkbox name="Dysgeusia" value="Y|N"]
Sputum [checkbox name="Productive Cough" value="Y|N"]
Hemoptysis [checkbox name="Hemoptysis" value="Y|N"]
Wheezing [checkbox name="Wheezing" value="Y|N"]
Chest Pain [checkbox name="Chest Pain" value="Y|N"]
Myalgia/Arthalgia [checkbox name="Myalagia" value="Y|N"]
Abdominal Pain [checkbox name="Abdominal Pain" value="Y|N"]
Nausea/Vomiting [checkbox name="Nausea/Vomiting" value="Y|N"]
Diarrhea [checkbox name="Diarrhea" value="Y|N"]
Adenopathy [checkbox name="Adenopathy" value="Y|N"]
Rash [checkbox name="Rash" value="Y|N"]
Fatigue/Malaise [checkbox name="Fatigue/Malaise" value="Y|N"]
Headache [checkbox name="Headache" value="Y|N"]
Confusion [checkbox name="Confusion" value="Y|N"]
Insomnia [checkbox name="Insomnia" value="Y|N"]
Anorexia [checkbox name="Anorexia" value="Y|N"]

Notes: [textarea name="SsxNotes" default=""]

PHYSICAL EXAM
Temperature [text name="temp" default=""]
Increased work of breathing [checkbox name="increased WOB on exam" value="Y|N"]
Cyanosis [checkbox name="Cyanosis on exam" value="Y|N"]
Retractions [checkbox name="Retractions on exam" value="Y|N"]
Walk Test
[text name="walk test" default=""]
O2 sat reading at rest [text name="O2 Sat" default=""]

DIAGNOSTIC TESTING:
[checkbox name="NoAddtlTesting" value="No further evaluation completed to date"]
Bloodwork [text name="bloodwork" default=""]
Chest X Ray [text name="CXR" default=""]
Microbiology [text name="Micro" default=""]
Other [text name="other workup" default=""]

IMPRESSION AND PLAN
Clinical Status [checkbox name="Clinical Status" value="Stable|Improving|Deteriorating"]

Disposition Plan
[checkbox name="Dispo Plan" value="Maintain at Home|Transfer to Hospital"]

Other Recommendations:
[textarea name="Recommendations" default=""]


Adapted fromL Lam PW et al. A virtual care program for outpatients diagnosed with Covid19: a feasibility study. CMAJ Open 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252690/pdf/cmajo.20200069.pdf
Date of Virtual Assessment:

DEMOGRAPHICS
Name:
Age:
Sex
Pregnant:
Healthcare Worker (HCW):

ONSET OF SYMPTOMS
Symptom onset (date of first symptom)
Have you had a fever? If yes,Date of first fever (>38.0)
Date of COVID Test Positive

Travel in the 14 days prior to first symptom onset
If yes, Country?

City/Geographic Area:
Did you have a known/identified COVID Exposure?

If yes: Date of Exposure:
Location of Exposure:


PAST MEDICAL HISTORY/CO-MORBIDITIES

Cardiac disease
Chronic lung Disease
Asthma
Smoker
Chronic kidney disease
Moderate or severe liver
disease
Chronic neurological issues
Malignancy
Chronic hematologic disease
HIV
Diabetes
Hypertension
Rheumatic disorder

Notes:


CURRENT SYMPTOMS
Fever
Sore Throat
Runny Nose
Cough
Are you short of breath?
Are you breathing harder or faster
when doing nothing at all?
Are you breathing faster than normal?
Does anything make you breathless today
that didn’t make you breathless
yesterday?
Chills/Rigors
Conjunctivitis
Ear Pain
Anosmia
Dysgeusia
Sputum
Hemoptysis
Wheezing
Chest Pain
Myalgia/Arthalgia
Abdominal Pain
Nausea/Vomiting
Diarrhea
Adenopathy
Rash
Fatigue/Malaise
Headache
Confusion
Insomnia
Anorexia

Notes:

PHYSICAL EXAM
Temperature
Increased work of breathing
Cyanosis
Retractions
Walk Test

O2 sat reading at rest

DIAGNOSTIC TESTING:

Bloodwork
Chest X Ray
Microbiology
Other

IMPRESSION AND PLAN
Clinical Status

Disposition Plan


Other Recommendations:



Adapted fromL Lam PW et al. A virtual care program for outpatients diagnosed with Covid19: a feasibility study. CMAJ Open 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252690/pdf/cmajo.20200069.pdf

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