COVID-19 Case Report form Survey

Thank you for reporting a case of interest. Please note that the detailed information recorded here will not be shared. We will provide summary information of interest in due course. Please complete as much information as you are able. If you agree we may come back to you for further information.

1.Submitter contact information (this information is strictly confidential -- the League will only contact you if you give permission)

Email Address

Case detail

2.Reason for report (select all that apply)

New neurological finding: hyposmia/anosmia, headaches, lethargy/sedation, weakness, other (please specify)

4.Sex

Male

Female

Other

5.Pre-existent diagnosis of epilepsy

Yes

No

7.Pre-existent diagnosis of neurological disease

Yes

No

8.Diagnosis

9.COVID-19 status: Select one

Positive

Presumed

11.COVID-19 severity

Mild disease
(Not requiring hospitalization -- OR -- Hospitalized patient with (SPO2 > 93%), and NO radiographic evidence of pneumonia)

Moderate disease
(Hospitalized patients with hypoxia (SPO2 < 94 %) OR Radiographic evidence of pneumonia)

Severe disease with respiratory failure but no other end organ damage
(Patient requiring high flow, NRB, BIPAP, or mechanical ventilation AND not on pressors, CrCl > 30 ml/min, ALT < 5x upper limit of normal)

Severe disease with respiratory failure and other end organ damage

Evidence of systemic inflammation (cytokine release syndrome)
(Worsening of respiratory function with evidence of systemic inflammation including elevations of IL-6, fibrinogen, d-dimer, CRP)

12.Treatment - Please list

Antiepileptic drugs

Other for COVID-19

15.Would you be willing to be contacted for further information for research purposes?

Yes

No