Name of reporter* must provide value
Email address of reporter* must provide value
Please enter professional/institutional email address only
Suspected or confirmed case of COVID-19?* must provide value
Suspected Confirmed
_todays_date Today D-M-Y
Date of onset of the symptoms of COVID-19. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Please return at least 7 days after the onset of symptoms to complete this form. Age* must provide value
years
Country where patient has been assessed* must provide value
--- Not in this country list --- Åland Islands Afghanistan Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Côte dIvoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Ré union Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Vietnam Virgin Islands, British Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Gender* must provide value
Female Male Other
Ethnicity* must provide value
White (Europe, Russia, Middle East, North Africa, U.S.A., Canada, Australia) Black - African Afro Caribbean African American Asian-Chinese South Asian (India, Pakistan, Sri Lanka, Nepal, Bhutan, Bangladesh) Asian-other (Korea, China north of Huai River) Japanese Hispanic or Latino Unknown other
Please specify other ethnicity* must provide value
Occupation
Weight* must provide value
kilograms
Height centimetres
Calculated BMI View equation
kg/m2
Psoriasis phenotype (check all that apply)* must provide value
Plaque
Pustular
Erythrodema
Pustular psoriasis phenotype* must provide value
Generalized pustular psoriasis Palmoplantar pustulosis Acrodermatitis continua of Hallopeau
Age of onset of psoriasis years
Psoriatic arthritis* must provide value
Yes No Unknown
Physician Global Assessment (PGA) recorded closest to COVID-19 onset* must provide value
Clear
Nearly clear
Mild
Moderate
Moderate-severe
Severe
Date of PGA (as recorded above). If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
PASI score closest to COVID-19 onset
Date of PASI. If exact date not known, please give most accurate estimate. Today D-M-Y DD-MM-YYYY
Body surface area (BSA) involvement closest to COVID-19 onset 0 - 100 %
Date of BSA. If exact date not known, please give most accurate estimate. Today D-M-Y DD-MM-YYYY
Since COVID-19 onset, has the patient's psoriasis* must provide value
Improved
Worsened
Remained same
Unknown
Please detail changes in psoriasis (e.g. change in PGA, phenotype) and timing of these changes* must provide value
The option "
Which systemic/biologic medication(s) was the patient on at the time of COVID-19 onset (include medications stopped within 4 weeks of COVID-19 onset)? (check all that apply)* must provide value
Methotrexate
Ciclosporin
Acitretin
Fumaric acid esters
Apremilast
Etanercept
Infliximab
Adalimumab
Golimumab
Certolizumab pegol
Ustekinumab
Secukinumab
Ixekizumab
Brodalumab
Guselkumab
Tildrakizumab
Risankizumab
Prednisolone
Dexamethasone
Other - free text
None
Methotrexate questions Methotrexate - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Methotrexate - Dose of treatment?* must provide value
2.5 to 30.0 mg (note one decimal point required e.g. 20.0)
Methotrexate - Intended dosing interval* must provide value
Weekly Other
Methotrexate - Please specify intended dosing interval* must provide value
Methotrexate - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Methotrexate - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Methotrexate - Was the medication restarted?* must provide value
Yes No Unknown
Methotrexate - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ciclosporin questions Ciclosporin - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ciclosporin - Dose of treatment?* must provide value
0 - 750 mg
Ciclosporin - Intended dosing interval* must provide value
Daily Other
Ciclosporin - Please specify intended dosing interval* must provide value
Ciclosporin - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Ciclosporin - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ciclosporin - Was the medication restarted?* must provide value
Yes No Unknown
Ciclosporin - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Acitretin questions Acitretin - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Acitretin - Dose of treatment?* must provide value
5 - 100 mg
Acitretin - Intended dosing interval* must provide value
Daily Other
Acitretin - Please specify intended dosing interval* must provide value
Acitretin - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Acitretin - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Acitretin - Was the medication restarted?* must provide value
Yes No Unknown
Acitretin - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Fumaric acid esters questions Fumaric acid esters - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Fumaric acid esters - Dose of treatment?* must provide value
30 - 720 mg
Fumaric acid esters - Intended dosing interval* must provide value
Daily Other
Fumaric acid eaters - Please specify intended dosing interval* must provide value
Fumaric acid esters - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Fumaric acid esters - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Fumaric acid esters - Was the medication restarted?* must provide value
Yes No Unknown
Fumaric acid esters - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Apremilast questions Apremilast - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Apremilast - Dose of treatment?* must provide value
30mg Other
Apremilast - Please specify dose of treatment* must provide value
5 - 60 mg
Apremilast - Intended dosing interval* must provide value
Twice daily Other
Apremilast - Please specify intended dosing interval* must provide value
Apremilast - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Apremilast - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Apremilast - Was the medication restarted? * must provide value
Yes No Unknown
Apremilast - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Etanercept questions Etanercept - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Etanercept - Dose of treatment?* must provide value
25mg 50mg Other
Etanercept - Please specify dose of treatment* must provide value
mg
Etanercept - Intended dosing interval* must provide value
Weekly Twice weekly Other
Etanercept - Please specify intended dosing interval* must provide value
Etanercept - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Etanercept - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Etanercept - Was the medication restarted?* must provide value
Yes No Unknown
Etanercept - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Infliximab questions Infliximab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Infliximab - Dose of treatment?* must provide value
5mg/kg Other
Infliximab - Please specify dose of treatment* must provide value
mg/kg
Infliximab - Intended dosing interval* must provide value
Every 6 weeks Every 8 weeks Other
Infliximab - Please specify intended dosing interval* must provide value
Infliximab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Infliximab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Infliximab - Was the medication restarted?* must provide value
Yes No Unknown
Infliximab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Adalimumab questions Adalimumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Adalimumab - Dose of treatment?* must provide value
40mg Other
Adalimumab - Please specify dose of treatment* must provide value
mg
Adalimumab - Intended dosing interval* must provide value
Fortnightly Weekly Other
Adalimumab - Please specify intended dosing interval* must provide value
Adalimumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Adalimumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Adalimumab - Was the medication restarted?* must provide value
Yes No Unknown
Adalimumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Golimumab questions Golimumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Golimumab - Dose of treatment?* must provide value
50mg 100mg Other
Golimumab - Please specify dose of treatment* must provide value
mg
Golimumab - Intended dosing interval* must provide value
Monthly Other
Golimumab - Please specify intended dosing interval* must provide value
Golimumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Golimumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Golimumab - Was the medication restarted?* must provide value
Yes No Unknown
Golimumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Certolizumab pegol questions Certolizumab pegol - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Certolizumab pegol - Dose of treatment?* must provide value
200mg 400mg Other
Certolizumab pegol - Please specify dose of treatment* must provide value
mg
Certolizumab pegol - Intended dosing interval* must provide value
Fortnightly Other
Certolizumab pegol - Please specify intended dosing interval* must provide value
Certolizumab pegol - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Certolizumab pegol - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Certolizumab pegol - Was the medication restarted?* must provide value
Yes No Unknown
Certolizumab pegol - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ustekinumab questions Ustekinumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ustekinumab - Dose of treatment?* must provide value
45mg 90mg Other
Ustekinumab - Please specify dose of treatment* must provide value
mg
Ustekinumab - Intended dosing interval* must provide value
Every 8 weeks Every 12 weeks Other
Ustekinumab - Please specify intended dosing interval* must provide value
Ustekinumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Ustekinumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ustekinumab - Was the medication restarted?* must provide value
Yes No Unknown
Ustekinumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Secukinumab questions Secukinumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Secukinumab - Dose of treatment?* must provide value
150mg 300mg Other
Secukinumab - Please specify dose of treatment* must provide value
mg
Secukinumab - Intended dosing interval* must provide value
Monthly Other
Secukinumab - Please specify intended dosing interval* must provide value
Secukinumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Secukinumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Secukinumab - Was the medication restarted?* must provide value
Yes No Unknown
Secukinumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ixekizumab questions Ixekizumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ixekizumab - Dose of treatment?* must provide value
80mg Other
Ixekizumab - Please specify dose of treatment* must provide value
mg
Ixekizumab - Intended dosing interval* must provide value
Every 2 weeks Every 4 weeks Other
Ixekizumab - Please specify intended dosing interval* must provide value
Ixekizumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Ixekizumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Ixekizumab - Was the medication restarted?* must provide value
Yes No Unknown
Ixekizumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Brodalumab questions Brodalumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Brodalumab - Dose of treatment?* must provide value
210mg Other
Brodalumab - Please specify dose of treatment* must provide value
mg
Brodalumab - Intended dosing interval* must provide value
Fortnightly Other
Brodalumab - Please specify intended dosing interval* must provide value
Brodalumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Brodalumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Brodalumab - Was the medication restarted?* must provide value
Yes No Unknown
Brodalumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Guselkumab questions Guselkumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Guselkumab - Dose of treatment?* must provide value
100mg Other
Guselkumab - Please specify dose of treatment* must provide value
mg
Guselkumab - Intended dosing interval* must provide value
Every 8 weeks Other
Guselkumab - Please specfiy intended dosing interval* must provide value
Guselkumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Guselkumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Guselkumab - Was the medication restarted?* must provide value
Yes No Unknown
Guselkumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Tildrakizumab questions Tildrakizumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Tildrakizumab - Dose of treatment?* must provide value
100mg 200mg Other
Tildrakizumab - Please specify dose of treatment* must provide value
mg
Tildrakizumab - Intended dosing interval* must provide value
Every 12 weeks Other
Tildrakizumab - Please specify intended dosing interval* must provide value
Tildrakizumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Tildrakizumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Tildrakizumab - Was the medication restarted?* must provide value
Yes No Unknown
Tildrakizumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Risankizumab questions Risankizumab - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Risankizumab - Dose of treatment?* must provide value
150mg Other
Risankizumab - Please specify dose of treatment* must provide value
mg
Risankizumab - Intended dosing interval* must provide value
Every 12 weeks Other
Risankizumab - Please specify intended dosing interval* must provide value
Risankizumab - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Risankizumab - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Risankizumab - Was the medication restarted?* must provide value
Yes No Unknown
Risankizumab - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Prednisolone questions Prednisolone - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Prednisolone - Dose of treatment?* must provide value
0 - 80 mg
Prednisolone - Intended dosing interval* must provide value
Daily Other
Prednisolone - Please specify intended dosing interval* must provide value
Prednisolone - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Prednisolone - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Prednisolone - Was the medication restarted?* must provide value
Yes No Unknown
Prednisolone - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Dexamethasone questions Dexamethasone - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Dexamethasone - Dose of treatment?* must provide value
0 - 50 mg
Dexamethasone - Intended dosing interval* must provide value
Daily Other
Dexamethasone - Please specify intended dosing interval* must provide value
Dexamethasone - Medication stopped during COVID-19?* must provide value
Yes No Unknown
Dexamethasone - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Dexamethasone - Was the medication restarted?* must provide value
Yes No Unknown
Dexamethasone - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
Other questions Systemic/biologic medication given* must provide value
______ - Start date of treatment? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
______ - Dose of treatment (with unit)?* must provide value
______ - Intended dosing interval* must provide value
______ - Medication stopped during COVID-19?* must provide value
Yes No Unknown
______ - Last administered dose. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
______ - Was the medication restarted?* must provide value
Yes No Unknown
______ - What date was the medication restarted? If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y DD-MM-YYYY
The option "
Did the patient have any of the following coexisting disorders at time of suspected or confirmed COVID-19? (check all that apply)* must provide value
Cardiovascular disease (e.g. coronary artery disease, heart failure, arrhythmia)
Diabetes
Asthma
COPD
Other chronic lung disease (NOT asthma/COPD)
Hypertension
Cancer
History of stroke
Chronic kidney disease (CKD)
Chronic liver disease (e.g. primary sclerosing cholangitis, non-alcoholic fatty liver disease, cirrhosis)
Alcohol excess
Obesity (BMI of 30 or more)
AIDS/HIV
Dementia
Inflammatory Bowel Disease
Organ transplant recipient
Rheumatologic or connective tissue diseases (excluding psoriatic arthritis)
Pulmonary hypertension
Anxiety
Depression
Other - free text
None
Please specify type of cancer* must provide value
Please specify type of rheumatologic or connective tissue disease* must provide value
Please specify patient coexisting disorder at time of suspected or confirmed COVID-19 infection?* must provide value
At time of COVID-19 was the patient pregnant? Yes No Unknown
Number of weeks gestation
At the time of COVID-19 was the patient post-partum (< 6 weeks)? Yes No Unknown
Smoking status of patient Current smoker
Former smoker
Never smoked
Unknown
Does the patient currently use e-cigarettes or vape? Yes No Unknown
At the time of COVID-19 was the patient taking any of the following medications? 1
2
3
4
5
Please specify other medication patient was taking at the time of COVID-19?* must provide value
The option "
Which signs and symptoms did the patient suffer from at the time of COVID-19? (check all that apply) General
Cardiorespiratory
Neurological
ENT
Gastrointestinal
None
Other - free text
General - sign and symptoms patient suffered from? (check all that apply) Fever
Muscle aches (Myalgia)
Joint pain (Arthralgia)
Fatigue (Malaise)
Conjunctivitis
Lymphadenopathy
Bleeding (Hemorrhage)
Cardiorespiratory - signs and symptoms patient suffered from. (check all that apply) Dry continuous cough
Cough with sputum production
Bloody sputum (hemoptysis)
Sore throat
Runny nose (Rhinorrhea)
Wheezing
Chest pain
Shortness of breath (Dyspnea)
Neurological - signs and symptoms the patient suffered from. (check all that apply) Headache
Altered consciousness
Confusion
Seizures
ENT - signs and symptoms patient suffered from. (check all that apply) Ear pain
Anosmia (loss of smell)
Dysgeusia (disturbance in sense of taste)
Gastrointestinal - signs and symptoms patient suffered from. (check all that apply) Abdominal pain
Vomiting
Nausea
Diarrhoea
Please specify which signs and symptoms the patient suffered from at the time of COVID-19?* must provide value
Have the symptoms resolved? Yes No Not applicable
Number of days of symptoms from COVID-19?* must provide value
days
Did the patient have any close contacts diagnosed with COVID-19? Yes No Unknown
Was the patient evaluated in hospital Accident & Emergency (Emergency Room)?* must provide value
Yes No Unknown
Region of hospital* must provide value
Not applicable North East and North Cumbria North West Coast Yorkshire and Humber Greater Manchester East Midlands West Midlands West of England Thames Valley and South Midlands Eastern Surrey and Sussex Wessex South West Peninsula North Thames South London North West London Northern Ireland Scotland Wales
Region of hospital* must provide value
Was the patient hospitalized?* must provide value
Yes No Unknown
Region of hospital* must provide value
Not applicable North East and North Cumbria North West Coast Yorkshire and Humber Greater Manchester East Midlands West Midlands West of England Thames Valley and South Midlands Eastern Surrey and Sussex Wessex South West Peninsula North Thames South London North West London Northern Ireland Scotland Wales
Did the patient participate in the UK Government shielding protection scheme?* must provide value
Yes No
Region of hospital* must provide value
Length of stay days
What was the maximum level of care required during the illness? (check all that apply)* must provide value
Did not require supplemental oxygen
Required oxygen by mask or nasal prongs
Required oxygen by non-invasive ventilation or high flow oxygen devices
Required intubation and mechanical ventilation
Required ECMO
Ventilation required, but type unknown
Interventions unknown
Other - free text
Please specify the maximum level of care required during the illness?* must provide value
Did the patient have any immediate complications?* must provide value
Yes No Unknown
Did the patient have any dermatological complications? Yes No Unknown
Please specify dermatological complications?* must provide value
What other complications did the patient suffer from? (check all that apply) Viral pneumonitis
Bacterial pneumonia
Acute Respiratory Distress Syndrome
Pneumothorax
Pleural effusion
Cryptogenic organizing pneumonia (COP)
Bronchiolitis
Meningitis or Encephalitis
Seizure
Stroke or Cerebrovascular accident
Congestive heart failure
Endocarditis or Myocarditis or Pericarditis
Cardiac arrhythmia
Cardiac ischaemia
Cardiac arrest
Bacteremia
Coagulation disorder or Disseminated Intravascular Coagulation
Anaemia
Rhabdomyolysis or Myositis
Acute renal injury or Acute renal failure
Gastrointestinal haemorrhage
Pancreatitis
Liver dysfunction
Hyperglycemia
Hypoglycemia
Other - Free text
Please specify what other complications the patient suffered from?* must provide value
Please specify severity of Acute Respiratory Distress Syndrome* must provide value
Mild
Moderate
Severe
Unknown
What treatment (including investigational therapy) was commenced for COVID-19? (check all that apply)* must provide value
No medications and/or investigational therapies used
Remdesivir
Chloroquine
Hydroxychloroquine
Oseltamivir
Lopinavir + ritonavir
Tocilizumab
Corticosteriods
Interferon beta-1a
Unknown
Other - free text
Please specify what treatment (including investigational therapy) was commenced for COVID-19?* must provide value
Blood counts Lymphocyte count one decimal place required e.g. 6.0
Lymphocyte date Today D-M-Y DD-MM-YYYY
Neutrophil count one decimal place required e.g. 6.0
Neutrophil date Today D-M-Y DD-MM-YYYY
Neutrophil/lymphocyte ratio View equation
WCC one decimal place required e.g. 6.0
WCC date Today D-M-Y DD-MM-YYYY
CRP one decimal place required e.g. 6.0
CRP date Today D-M-Y DD-MM-YYYY
Platelet count one decimal place required e.g. 6.0
Platelet count date Today D-M-Y DD-MM-YYYY
What was the clinical outcome?* must provide value
Death
Recovery
Any chronic complication
Death date. If exact date not known, please give most accurate estimate.* must provide value
Today D-M-Y
Recorded cause of death* must provide value
Please specify any chronic complication* must provide value
Do you also enter data into any of the following psoriasis registries? (check all that apply) Do you also enter data into any of the following psoriasis registries? (check all that apply)* must provide value
No
AMC Psoriasis Registry (Netherlands)
Australasian Psoriasis Registry (Australia)
BADBIR (UK and Ireland)
Biobadaderm (Spain)
Bio-CAPTURE (Netherlands)
BIOREP (Czech Republic)
Clalit Health Services (Israel)
DermBio (Denmark)
MRP (Malaysia)
PsoBest (Germany)
Psobioteq (France)
PSOCARE or PSODIT (Italy)
PSOLAR (International)
PsoRA (Austria)
PsoReg (Sweden)
Registry of Slovenian Psoriasis Patients (Slovenia)
SDNTT (Switzerland)
Other - free text
AMC Psoriasis Registry (Netherlands)
Australasian Psoriasis Registry (Australia)
BADBIR (UK and Ireland)
Biobadaderm (Spain)
Bio-CAPTURE (Netherlands)
BIOREP (Czech Republic)
Clalit Health Services (Israel)
DermBio (Denmark)
MRP (Malaysia)
PsoBest (Germany)
Psobioteq (France)
PSOCARE or PSODIT (Italy)
PSOLAR (International)
PsoRA (Austria)
PsoReg (Sweden)
Registry of Slovenian Psoriasis Patients (Slovenia)
SDNTT (Switzerland)
Other - free text
No
Please specify registry name and country* must provide value
Has this case also been entered into any other COVID-19 registry?* must provide value
Yes No Unknown
Which COVID-19 registry has the case also been entered into? Other - free text
None
Please specify which other COVID-19 registry the case has also been entered into?
Would you like to receive email updates on this, and future studies? Your email contact will be stored safely, we will not use it for any other purpose, and you can opt out at any time by contacting us as at psoprotect@kcl.ac.uk . * must provide value
Yes No
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