Reporting of COVID-19 cases in SCD in Florida

This form is to be completed by a health care professional caring for a patient with sickle cell disease and documented coronavirus (COVID 19). Please report only confirmed COVID-19 cases, and report after sufficient time has passed to observe the disease course through resolution of acute illness and/or death. Fields marked with a red asterisk (*) are required.

First Name*

Last Name*

Email Address*

Phone Number

Extension

Zipcode*

Degree

MD
DO
ARNP
MPH
RN
Administrator
LSCW
PharmD
Other

Please Explain

Patient Information

Age, in years*

County of residence*

Gender*

Female
Male
Other

Race (may check more than one)

White
Black or African American
American Indian / Native Alaskan
Asian
Native Hawaiian / Pacific Islander
Other

Please Explain

Ethnicity*

Please Explain

Disease factors Sickle Cell genotype:

Hemoglobin SS disease
Hemoglobin S beta zero thalassemia
Hemoglobin SC disease
Hemoglobin S beta + thalassemia
Other/Unknown

Please Explain

Primary Language

Sickle cell disease-related history:

Pain: Number of times hospitalized for pain in the last 3 years

If this is unknown please enter "999"; if the patient has never experienced this enter "0"

Pain: Number of treat and release emergency department visits for pain requiring IV opioids in last 3 years

If this is unknown please enter "999"; if the patient has never experienced this enter "0"

Acute chest syndrome: Number of episodes in last 3 years

If this is unknown please enter "999"; if the patient has never experienced this enter "0"

Priapism: Number of episodes in last 3 years

If this is unknown please enter "999"; if the patient has never experienced this enter "0"

Brain: Overt Stroke history

Yes
No

Brain: Silent Stroke History

Yes
No

Brain: Known CNS vasculopathy

Yes
No

Brain: High TCD result (Transcranial Doppler)

Yes
No

Heart/Lung: Pulmonary hypertension

Yes
No

Kidney disease: Albuminuria

Yes
No

Kidney disease: Decreased Renal function

Yes
No

Kidney disease: Sickle cell disease nephropathy

Yes
No

Splenic Sequestration

Yes
No

Does the patient have any of the following comorbidities?

Does the patient have any of the following comorbidities (check all that apply)?

Please Explain

COVID 19 Questions

Date of diagnosis of COVID-19?

Patient Hospital Admission Date

Patient Hospital Discharge Date

Specify approximate number of days of symptoms from COVID 19 (if known)

Please choose a severity of COVID-19

Asymptomatic-no clinical signs or symptoms during the positive COVID-19 period.
Mild- symptoms of acute upper respiratory tract infection, including fever, fatigue, myalgia, cough, sore throat, runny nose, and sneezing or gastrointestinal symptoms or digestive symptoms such as nausea, vomiting, abdominal pain and diarrhea.
Moderate-pneumonia, with or without clinical symptoms, no hypoxia
Severe-early respiratory symptoms or gastrointestinal symptoms followed by dyspnea and hypoxia (O2 saturations less than 92%)
Critical-ARDS, respiratory failure, encephalopathy, shock, coagulopathy, multi-organ impairment (lung, heart, kidney, brain) that may be life threatening

Have patient's symptoms resolved at the time of this report?

Yes
No
Unknown
Patient never developed symptoms (just tested positive)

Did patient develop any of these sickle cell disease symptoms at the time of COVID 19 infection?

Stroke

Yes
No

Acute chest syndrome/pneumonia

Yes
No

Pain

Yes
No

Priapism

Yes
No

Splenic sequestration

Yes
No

Aplastic crisis

Yes
No

Pulmonary hypertension

Yes
No

Heart arrhythmias

Yes
No

Heart failure

Yes
No

Kidney failure

Yes
No

Bacterial infection

Yes
No

COVID 19 Treatment

Did patient die of COVID 19 or other complications caused by or contributed to by COVID 19?

Yes
No
Unknown

Was patient evaluated in a hospital ER?

Yes
No
Unknown

Has the patient been hospitalized?

Yes
No
Unknown

Is patient living?

Yes
No

Date of death

Place of Death

ED
Hospital
Home

Aditional Comments (Optional)

Your information is HIPAA-protected and will not be shared with any third-party. By filling out this form, you agree to be contacted by the Foundation for Sickle Cell Disease Research, to better assist you.

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Reporting of COVID-19 cases in SCD in Florida