Demographics | |
 | Sex |
 | Age |
 | Ethnicity |
Medical history | |
COVID-19 history and management | Intended for hospital or for community management |
Co-morbidities | Chronic kidney disease |
 | Hypertension |
 | Diabetes |
 | Cardiovascular disease (including heart failure, ischemic heart disease, acute myocardial infarction, congenital heart disease, stroke, peripheral vascular disease) |
 | Cancer in last 5 years (not including basal cell carcinoma and squamous cell carcinoma) |
 | Chronic respiratory illness |
 | Severe liver disease (Child-Pugh-Turcotte score 10–15 or biliary obstruction) |
 | Other relevant medical conditions |
 | Pregnancy status (pregnant or breastfeeding) |
Medications | Renin-angiotensin-aldosterone system (RAAS) inhibitor (including ACEi, ARB, aldosterone antagonist, angiotensin receptor-neprilysin inhibitor, Aliskiren) |
 | Non-RAAS inhibitor blood pressure (BP)-lowering agent |
 | Glucose-lowering medication |
 | Steroids |
 | Steroid inhalers/nasal spray |
 | COVID-19-specific therapies |
 | Other immunosuppressants |
 | Other inhalers |
 | Vasopressor |
 | Proton-pump inhibitor (e.g. omeprazole, esomeprazole, pantoprazole) |
 | Aspirin |
 | Lipid-lowering agent (e.g. statins, fibrates) |
 | Antimicrobials |
 | Other |
Smoking status | Current, previous, non-smoker |
Physical examination | |
 | Blood pressure (mmHg) |
 | Height (cm) |
 | Weight (kg) |
 | Body mass index (kg/m2) |
Laboratory measures | |
 | Serum creatinine (mg/dL) |
 | Estimated glomerular filtration rate (mL/min/1.73 m2) |
 | White cell count (x 109/L) |
 | Neutrophils and lymphocytes (x 109/L) |
 | D-Dimer (mg/L FEU or mg/L DDU) |
 | C-reactive protein (mg/L or nmol/L) |
 | Creatine kinase (U/L) |