[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