COVID19P / SARS COV2 y SIM Realidad en LATAM SISIAC encuesta COVID19 Pediatrico- y Sindrome Inflamatorio Multi-sistemico (SIM) Sponsorizado por SISIAC
User name:
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User email:
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User city:
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User country:
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User specialty:
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Primary Care
General Pediatrician
Pediatric Infectious Disease
Pediatric Intensive Care
Pediatric Cardiology
Pediatric Rheumatology
Nursing
Epidemiologist
Laboratory professional
Other Pediatric Specialty
Other pediatric specialty:
Patient date of birth(Day/Month/Year):
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Today D-M-Y
Patient Initials (First Name initial. Last Name initial.):
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Patient age:
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years
Date of first medical encounter (Day/Month/Year):
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Today D-M-Y
Patient sex:
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Female
Male
Other
enter "." if unknown or wish not to answer
Patient weight (kg):
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kg
This patient had (check all that apply):
This patient had (check all that apply):
* must provide value
What was the 1st symptom?
Respiratory symptoms
Cardiovascular symptoms
Neurological symptoms
Gastrointestinal symptoms
Fever
COVID-19 (SARS COV2) testing
Skin symptoms
Admission to hospital timing:
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Respiratory symptoms (check all that apply):
Accessory respiratory muscle use (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Cough (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Inspiratory stridor (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Shortness of breath (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Expiratory wheezing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Superinfected by non-SARS COV2 organism (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Cardiovascular symptoms (check all that apply):
Abnormal Echocardiography (check all that apply):
Dilated left ventricle (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
LVEF < 50% (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Valvar regurgitation (moderate or severe), (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Coronary aneurysm Z score over 2.5
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Pericardial effusion (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Arrhythmia (check all that apply):
Atrioventricular block (1st, 2nd, or 3rd degree), (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
PAC's (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
PVC's (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
ST segment changes (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Supraventricular tachycardia changes, (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Ventricular tachycardia changes, (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Myocarditis diagnosis (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Peripheral edema (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Pulmonary embolism (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Other embolism (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Coronary artery dilation or aneurysm
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Neurological symptoms (check all that apply):
Headache (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Hemorrhagic stroke (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Ischemic stroke (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Loss of smell or taste (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Meningitis (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Peripheral neuropathy (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Gastrointestinal symptoms (check all that apply):
Abdominal pain (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Diarrhea (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Loss of appetite / Anorexia (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Nausea (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Vomiting (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Laboratory results (check all that apply):
Yes
No
Troponin I elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Yes
No
NT-proBNP elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Yes
No
BNP elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Creatinine eG FR < 50% of predicted (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Yes
No
ALT elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Yes
No
Elevated aPTT (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Yes
No
D dimer elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Is procalcitonin > 5x ULN ?
Yes
No
Procalcitonin elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
White blood cell count < 5K (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
White blood cell count > 10K (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Platelet < 150K (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Platelet > 600K (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Is C reactive protein > 10x ULN ?
Yes
No
C reactive protein elevated (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Arterial blood gas pH < 7.35 timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Arterial lactate > 2mmol/L timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Imaging (check all that apply):
Chest Xray Pneomonitis / pneumonia (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Chest Xray Pulmonary edema (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Chest CT scan abnormal (check at 1st occurrence):c
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
COVID-19 (SARS COV2) testing:
SARS COV2 PCR test positive (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 PCR test negative (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 antigen test positive (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 antigen test negative (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 IgM positive (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 IgM negative (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 IgG positive (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
SARS COV2 IgG negative (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Conjunctival injection (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Erythematous rash (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Lymph node swelling or tenderness (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Peeling skin (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Pernio (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Pruritus without visible rash (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Strawberry tongue (check at first occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Therapies (Check all that apply):
Antiarrhythmics (beta blockers, calcium channel blockers, diagoxin, amiodarone, sotalol, lidocaine, etc).
cPAP / biPAP
Direct thrombin inhibitor
Diuretic therapy
ECMO
Endotracheal ventilation
Heparin infusion / Low molecular weight heparin
Inhaled heliox
Inhaled nitric oxide
Inotropic infusion (Dopamine, Epinephrine, Milrinone, etc.)
Macrolide antibiotic
Oral anti factor Xa inhibitor (NOAC)
Oral pulmonary vasodilators
Protease inhibitor
t-PA / streptokinase / other thrombolytic
Supplemental oxygen by cannula
Systemic afterload reducers
Vasoconstrictor infusion (Norepinephrine, Vasopressin, etc.)
Warfarin
Other antibiotic
Other antiviral
Antiarrhythmics (beta blockers, calcium channel blockers, diagoxin, amiodarone, sotalol, lidocaine, etc) timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
cPAP / biPAP timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Direct thrombin inhibitor timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Diuretic therapy timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
ECMO timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Endotracheal ventilation timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
EndotHeparin infusion / Low molecular weight heparin timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Inhaled heliox timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Inhaled nitric oxide timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Inotropic infusion (Dopamine, Epinephrine, Milrinone, etc.) timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Macrolide antibiotic timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Oral anti factor Xa inhibitor (NOAC) timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Oral pulmonary vasodilators timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Protease inhibitor timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
t-PA / streptokinase / other thrombolytic timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Supplemental oxygen by cannula timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Systemic afterload reducers timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Vasoconstrictor infusion (Norepinephrine, Vasopressin, etc.) timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Warfarin timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Other antibiotic timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
Other antiviral timing (check at 1st occurrence):
1st symptom Within 2 days after 1st symptom 3-10 days after 1st symptom 11-21 days after 1st symptom Timing unclear
This patient had past history of (check all that apply):
* must provide value
Abnormal cholesterol timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Anti TNF a / IL-1 / IL-6 therapy timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Arrhythmia timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Asthma/reactive airways timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Chemotherapy use timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Cholesterol medicine timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Complex congenital heart disease timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Cystic fibrosis timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Disease modifying anti-inflammatory medicine timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Diuretic therapy timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Hematologic cancer timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Hematology disorder timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Hypertension timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Hypertension medicine (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Immunosuppressed / immunocompromised timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Inborn disorder of metabolism timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Inflammatory condition (Rheumatoid arthritis, systemic lupus, etc) timing: (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Mechanical ventilator timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Neuromuscular disorder timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Non-insulin diabetes medicine timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Polycystic ovarian syndrome timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Pregnancy timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Prematurity 24-32 weeks timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Prematurity 32-36 weeks timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Restrictive lung disease timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Sex hormone use timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Solid organ transplant timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Solid tumor cancer timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Tracheostomy timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Type 1 diabetes mellitus timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Type 2 diabetes mellitus timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
"Other" past history (check at 1st occurrence):
"Other" past history timing (check at 1st occurrence):
At presentation with SARS COV2 0-5 years before presentation >5 years before presentation
Any Special Notes about the patient?
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