Pediatric Inflammatory Multi-system Syndrome (PIMS) Initial Case Report Form
Report PIMS Cases to the UCSD KD Research Center.
SUBMITTER'S INFORMATION
Your Name *
Your answer
Your Institution *
Your answer
Your Email address *
Your answer
PATIENT'S INFORMATION
Date of onset of illness *
MM
/
DD
/
YYYY
Patien'ts Age (years). Ex. 1.5 = 1 year and 6 months *
Your answer
Patient's Sex *
Ethnicity *
Was patient diagnosed with Kawasaki Disease? *
Evidence of myocardial dysfunction requiring ICU-level care *
Result of SARS-CoV-2 NP swab PCR *
Result of SARS-CoV-2 Antibody *
Comments:
Your answer
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