COVID19 Virtual Follow-Up (CMAJ)
[text name="variable_1" default="sample text"] 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"] Number of Days since Symptom Onset: [text name="variable_1" default="sample text"] [checkbox name="NoReportedSSx" value="No reported symptoms"] TREATMENTS Antivirals [text name="antiviraltx" default=""] Other antimicrobials [text name="antimicrobialtx" default=""] Other medications [text name="othertx" 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
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Sandbox Metrics: Structured Data Index 0.71, 55 form elements, 160 boilerplate words, 14 text boxes, 2 text areas, 1 dates, 38 checkboxes, 94 total clicks
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