| | If yes, specify |
| Date of birth | | |
| Gender | | |
| Date of COVID-19 diagnosis | | |
| Outcome of COVID-19 infection | | |
| Previous lung disease Y/N | | |
| Previous or current cancer diagnosis | | |
| Other chronic condition | | |
| | |
| Weight | Kg | |
| BMI | | |
| | |
| On IVIG | |
| On prohylactic antibiotic | | |
| Current or recent chemotherapy | | |
| Current or recent corticosteroids | | |
| Most recent lab data prior to COVID-19 infection: |
| White blood count | /μl | |
| Neutrophil count | /μl | |
| Lymphocyte count | /μl | |
| CD4 count | /μl | |
| IgG | mg/l | |
| IgA | mg/l | |
| IgM | mg/l | |
| Sent by | | from |
| | |
