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V3-EJH COVID-19 DATA
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* Indicates required question
Patient MRN
*
Your answer
Respiratory Symptoms
*
Yes
No
Required
Height
*
Your answer
Weight
*
Your answer
Intubated
*
Yes
No
Intubation date
MM
/
DD
/
YYYY
Oxygen Therapy
*
Oxygen Therapy
No Oxygen Therapy
Invasive Ventilation
Non Invasive Ventilation
ECMO
*
Yes
No
Plasmapheresis
*
Yes
No
Renal Replacement
*
Yes
No
Previous Surgeries
*
Yes
No
Asthma
*
Yes
No
Diabetes
*
Yes
No
HTN
*
Yes
No
CRF
*
Yes
No
Cardiac Disease
*
Yes
No
Immunocompromised
*
Yes
No
Severe Obesity
*
Yes
No
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