Infectious Disease
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[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

Date of Virtual Assessment:

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

Number of Days since Symptom Onset:



TREATMENTS
Antivirals
Other antimicrobials
Other medications

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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