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PsoProtect - Psoriasis Patient Registry for Outcomes,
Therapy and Epidemiology of Covid-19 infecTion

This form is to be completed by a health care professional caring for a patient with psoriasis and coronavirus disease2019 (COVID-19). This form should be completed after the patient has had COVID-19 for a long enough duration toexperience partial or complete recovery, hospitalization or death. You can save and return to the form later if
needed.

Reporter Information
Name of reporter

Email address of reporter____________________________________________________________________(Please enter professional/institutional email
address only)

Patient Information
Suspected or confirmed case of COVID-19?
_todays_date

Date of onset of the symptoms of COVID-19. If exact
date not known, please give most accurate estimate.

Suspected

Confirmed____________________________________________________________________(DD-MM-YYYY)

Please return at least 7 days after the onset of symptoms to complete this form.
Age

27-04-2020 13:50__________________________________(years)projectredcap.org

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Country where patient has been assessed

27-04-2020 13:50--- Not in this country list --Åland Islands
Afghanistan
Albania
Algeria
AndorraAngolaAnguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
BahamasBahrain
Bangladesh
Barbados
BelarusBelgium
BelizeBenin
BermudaBhutanBolivia, Plurinational State ofBosnia and Herzegovina
Botswana
Bouvet Island
BrazilBritish Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
BurundiCôte dIvoire
Cambodia
Cameroon
CanadaCape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling)
Islands
Colombia
Comoros
Congo
Congo, the Democratic Republicof theCook Islands
Costa Rica
Croatia
Cuba
CyprusCzech Republic
DenmarkDjibouti
Dominica
Dominican Republic
EcuadorEgypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
FinlandFranceFrench Guiana
French Polynesia
French Southern
Territories
Gabon
GambiaGeorgia
Germany
Ghana
Gibraltar
GreeceGreenland
GrenadaGuadeloupe
Guatemala
Guernsey
GuineaGuinea-Bissau
GuyanaHaiti
Heard Island and
McDonald Islands
Holy See (Vatican City
State)
HondurasHong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
IrelandIsle of Man
IsraelItaly
JamaicaJapan
JerseyJordanKazakhstan
Kenya
Kiribati
Korea, Democratic Peoples
Republic ofKorea, Republic of
KuwaitKyrgyzstan
Lao Peoples Democratic Republic
LatviaLebanonLesothoLiberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the former Yugoslav RepublicofMadagascar
MalawiMalaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
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Mauritius
MayotteMexicoMicronesia, Federated StatesofMoldova, Republic of
MonacoMongolia
Montenegro
Montserrat
MoroccoMozambique
MyanmarNamibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
NorwayOman
Pakistan
Palau
Palestinian Territory, Occupied
PanamaPapua New Guinea
Paraguay
Peru
Philippines
Pitcairn
PolandPortugal
Qatar
Ré union
Romania
Russian Federation
RwandaSaint BarthélemySaint 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
SenegalSerbiaSeychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
SomaliaSouth Africa
South Georgia and theSouth Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
SwedenSwitzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic ofThailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
TurkeyTurkmenistan
Turks and Caicos Islands
TuvaluUgandaUkraineUnited Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian RepublicofVietnam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
ZambiaZimbabwe
GenderFemale

Male

Other

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Ethnicity

Please specify other ethnicity

Occupation

WeightHeightCalculated BMI

White (Europe, Russia, Middle East, North Africa,
U.S.A., Canada, Australia)
Black - African
Afro Caribbean
African American
Asian-ChineseSouth Asian (India, Pakistan, Sri Lanka, Nepal,
Bhutan, Bangladesh)
Asian-other (Korea, China north of Huai River)Japanese
Hispanic or Latino
Unknownother______________________________________________________________________________________________________(kilograms)__________________________________(centimetres)__________________________________(kg/m2)

Psoriasis
Psoriasis phenotype (check all that apply)

PlaquePustular
Erythrodema

Pustular psoriasis phenotype

Generalized pustular psoriasis
Palmoplantar pustulosis
Acrodermatitis continua of Hallopeau

Age of onset of psoriasis__________________________________(years)Psoriatic arthritis

Yes

Physician Global Assessment (PGA) recorded closest to
COVID-19 onset

Clear
Nearly clear
Mild
Moderate
Moderate-severe
SevereDate of PGA (as recorded above). If exact date notknown, please give most accurate estimate.

27-04-2020 13:50

No

Unknown__________________________________(DD-MM-YYYY)

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PASI score closest to COVID-19 onset

Date of PASI. If exact date not known, please give
most accurate estimate.

Body surface area (BSA) involvement closest to
COVID-19 onset

Date of BSA. If exact date not known, please give
most accurate estimate.

Since COVID-19 onset, has the patient's psoriasis

Please detail changes in psoriasis (e.g. change in
PGA, phenotype) and timing of these changes____________________________________________________________________(DD-MM-YYYY)__________________________________(0 - 100 %)__________________________________(DD-MM-YYYY)
Improved
Worsened
Remained same
Unknown__________________________________________

Psoriasis systemic/biologic medication(s)Which systemic/biologic medication(s) was the patienton at the time of COVID-19 onset (include
medications stopped within 4 weeks of COVID-19
onset)? (check all that apply)

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.

Methotrexate - Dose of treatment?

27-04-2020 13:50__________________________________(DD-MM-YYYY)__________________________________(2.5 to 30.0 mg (note one decimal point required
e.g. 20.0))

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Methotrexate - Intended dosing interval
Methotrexate - Please specify intended dosinginterval
Methotrexate - Medication stopped during COVID-19?
Methotrexate - Last administered dose. If exact date
not known, please give most accurate estimate.

Methotrexate - Was the medication restarted?
Methotrexate - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

WeeklyOther__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Ciclosporin questions
Ciclosporin - Start date of treatment? If exact date
not known, please give most accurate estimate.

Ciclosporin - Dose of treatment?

Ciclosporin - Intended dosing interval
Ciclosporin - Please specify intended dosing interval

Ciclosporin - Medication stopped during COVID-19?
Ciclosporin - Last administered dose. If exact date
not known, please give most accurate estimate.

Ciclosporin - Was the medication restarted?
Ciclosporin - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)__________________________________(0 - 750 mg)
Daily

Other

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Acitretin questions
Acitretin - Start date of treatment? If exact date
not known, please give most accurate estimate.

Acitretin - Dose of treatment?

27-04-2020 13:50__________________________________(DD-MM-YYYY)__________________________________(5 - 100 mg)

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Acitretin - Intended dosing interval
Acitretin - Please specify intended dosing interval

Acitretin - Medication stopped during COVID-19?
Acitretin - Last administered dose. If exact date notknown, please give most accurate estimate.

Acitretin - Was the medication restarted?
Acitretin - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

Daily

Other

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Fumaric acid esters questions
Fumaric acid esters - Start date of treatment? If
exact date not known, please give most accurate
estimate.
Fumaric acid esters - Dose of treatment?

Fumaric acid esters - Intended dosing interval
Fumaric acid eaters - Please specify intended dosinginterval
Fumaric acid esters - Medication stopped during
COVID-19?
Fumaric acid esters - Last administered dose. If
exact date not known, please give most accurate
estimate.
Fumaric acid esters - Was the medication restarted?
Fumaric acid esters - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

__________________________________(DD-MM-YYYY)__________________________________(30 - 720 mg)
Daily

Other

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Apremilast questions
Apremilast - Start date of treatment? If exact date
not known, please give most accurate estimate.

Apremilast - Dose of treatment?

27-04-2020 13:50__________________________________(DD-MM-YYYY)
30mg

Other

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Apremilast - Please specify dose of treatment

Apremilast - Intended dosing interval
Apremilast - Please specify intended dosing interval

Apremilast - Medication stopped during COVID-19?
Apremilast - Last administered dose. If exact date
not known, please give most accurate estimate.

Apremilast - Was the medication restarted?
Apremilast - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(5 - 60 mg)
Twice daily

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Etanercept questions
Etanercept - Start date of treatment? If exact date
not known, please give most accurate estimate.

Etanercept - Dose of treatment?
Etanercept - Please specify dose of treatment

Etanercept - Intended dosing interval

Etanercept - Please specify intended dosing interval

Etanercept - Medication stopped during COVID-19?
Etanercept - Last administered dose. If exact date
not known, please give most accurate estimate.

Etanercept - Was the medication restarted?
Etanercept - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
25mg

50mg

Other

__________________________________(mg)
WeeklyOther

Twice weekly__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Infliximab questions

27-04-2020 13:50

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Infliximab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Infliximab - Dose of treatment?
Infliximab - Please specify dose of treatment

Infliximab - Intended dosing interval

Infliximab - Please specify intended dosing interval

Infliximab - Medication stopped during COVID-19?
Infliximab - Last administered dose. If exact date
not known, please give most accurate estimate.

Infliximab - Was the medication restarted?
Infliximab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
5mg/kgOther__________________________________(mg/kg)Every 6 weeks
Other

Every 8 weeks__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Adalimumab questions
Adalimumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Adalimumab - Dose of treatment?
Adalimumab - Please specify dose of treatment

Adalimumab - Intended dosing interval

Adalimumab - Please specify intended dosing interval

Adalimumab - Medication stopped during COVID-19?
Adalimumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Adalimumab - Was the medication restarted?

27-04-2020 13:50__________________________________(DD-MM-YYYY)
40mg

Other

__________________________________(mg)
Fortnightly
Other

Weekly__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown

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Adalimumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)

Golimumab questions
Golimumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Golimumab - Dose of treatment?
Golimumab - Please specify dose of treatment

Golimumab - Intended dosing interval
Golimumab - Please specify intended dosing interval

Golimumab - Medication stopped during COVID-19?
Golimumab - Last administered dose. If exact date notknown, please give most accurate estimate.

Golimumab - Was the medication restarted?
Golimumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
50mg

100mg

Other

__________________________________(mg)
Monthly

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Certolizumab pegol questions
Certolizumab pegol - Start date of treatment? If
exact date not known, please give most accurate
estimate.
Certolizumab pegol - Dose of treatment?
Certolizumab pegol - Please specify dose of treatment

Certolizumab pegol - Intended dosing interval
Certolizumab pegol - Please specify intended dosinginterval
Certolizumab pegol - Medication stopped during
COVID-19?

27-04-2020 13:50__________________________________(DD-MM-YYYY)
200mg

400mg

Other

__________________________________(mg)
Fortnightly

Other__________________________________
Yes

No

Unknown

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Certolizumab pegol - Last administered dose. If exact
date not known, please give most accurate estimate.

Certolizumab pegol - Was the medication restarted?
Certolizumab pegol - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Ustekinumab questions
Ustekinumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Ustekinumab - Dose of treatment?
Ustekinumab - Please specify dose of treatment

Ustekinumab - Intended dosing interval

Ustekinumab - Please specify intended dosing interval

Ustekinumab - Medication stopped during COVID-19?
Ustekinumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Ustekinumab - Was the medication restarted?
Ustekinumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
45mg

90mg

Other

__________________________________(mg)
Every 8 weeks
Other

Every 12 weeks__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Secukinumab questions
Secukinumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Secukinumab - Dose of treatment?
Secukinumab - Please specify dose of treatment

Secukinumab - Intended dosing interval

27-04-2020 13:50__________________________________(DD-MM-YYYY)
150mg

300mg

Other

__________________________________(mg)
Monthly

Other

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Secukinumab - Please specify intended dosing interval

Secukinumab - Medication stopped during COVID-19?
Secukinumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Secukinumab - Was the medication restarted?
Secukinumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Ixekizumab questions
Ixekizumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Ixekizumab - Dose of treatment?
Ixekizumab - Please specify dose of treatment

Ixekizumab - Intended dosing interval

Ixekizumab - Please specify intended dosing interval

Ixekizumab - Medication stopped during COVID-19?
Ixekizumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Ixekizumab - Was the medication restarted?
Ixekizumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
80mg

Other

__________________________________(mg)
Every 2 weeks
Other

Every 4 weeks__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Brodalumab questions
Brodalumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Brodalumab - Dose of treatment?

27-04-2020 13:50__________________________________(DD-MM-YYYY)
210mg

Other

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Brodalumab - Please specify dose of treatment

Brodalumab - Intended dosing interval
Brodalumab - Please specify intended dosing interval

Brodalumab - Medication stopped during COVID-19?
Brodalumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Brodalumab - Was the medication restarted?
Brodalumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(mg)
Fortnightly

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Guselkumab questions
Guselkumab - Start date of treatment? If exact date
not known, please give most accurate estimate.

Guselkumab - Dose of treatment?
Guselkumab - Please specify dose of treatment

Guselkumab - Intended dosing interval
Guselkumab - Please specfiy intended dosing interval

Guselkumab - Medication stopped during COVID-19?
Guselkumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Guselkumab - Was the medication restarted?
Guselkumab - What date was the medication restarted?
If exact date not known, please give most accurate
estimate.

__________________________________(DD-MM-YYYY)
100mg

Other

__________________________________(mg)
Every 8 weeks

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Tildrakizumab questions
Tildrakizumab - Start date of treatment? If exact
date not known, please give most accurate estimate.

27-04-2020 13:50__________________________________(DD-MM-YYYY)

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Tildrakizumab - Dose of treatment?
Tildrakizumab - Please specify dose of treatment

Tildrakizumab - Intended dosing interval
Tildrakizumab - Please specify intended dosinginterval
Tildrakizumab - Medication stopped during COVID-19?
Tildrakizumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Tildrakizumab - Was the medication restarted?
Tildrakizumab - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

100mg

200mg

Other

__________________________________(mg)
Every 12 weeks

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Risankizumab questions
Risankizumab - Start date of treatment? If exact
date not known, please give most accurate estimate.

Risankizumab - Dose of treatment?
Risankizumab - Please specify dose of treatment

Risankizumab - Intended dosing interval
Risankizumab - Please specify intended dosinginterval
Risankizumab - Medication stopped during COVID-19?
Risankizumab - Last administered dose. If exact date
not known, please give most accurate estimate.

Risankizumab - Was the medication restarted?
Risankizumab - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

__________________________________(DD-MM-YYYY)
150mg

Other

__________________________________(mg)
Every 12 weeks

Other__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Prednisolone questions

27-04-2020 13:50

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Prednisolone - Start date of treatment? If exact
date not known, please give most accurate estimate.

Prednisolone - Dose of treatment?

Prednisolone - Intended dosing interval
Prednisolone - Please specify intended dosinginterval
Prednisolone - Medication stopped during COVID-19?
Prednisolone - Last administered dose. If exact date
not known, please give most accurate estimate.

Prednisolone - Was the medication restarted?
Prednisolone - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

__________________________________(DD-MM-YYYY)__________________________________(0 - 80 mg)
Daily

Other

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Dexamethasone questions
Dexamethasone - Start date of treatment? If exact
date not known, please give most accurate estimate.

Dexamethasone - Dose of treatment?

Dexamethasone - Intended dosing interval
Dexamethasone - Please specify intended dosinginterval
Dexamethasone - Medication stopped during COVID-19?
Dexamethasone - Last administered dose. If exact date
not known, please give most accurate estimate.

Dexamethasone - Was the medication restarted?
Dexamethasone - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

__________________________________(DD-MM-YYYY)__________________________________(0 - 50 mg)
Daily

Other

__________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)Other questions

27-04-2020 13:50

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Systemic/biologic medication given[patient_med_other] - Start date of treatment? If
exact date not known, please give most accurate
estimate.
[patient_med_other] - Dose of treatment (with unit)?

[patient_med_other] - Intended dosing interval[patient_med_other] - Medication stopped during
COVID-19?
[patient_med_other] - Last administered dose. If
exact date not known, please give most accurate
estimate.
[patient_med_other] - Was the medication restarted?
[patient_med_other] - What date was the medication
restarted? If exact date not known, please give
most accurate estimate.

____________________________________________________________________(DD-MM-YYYY)____________________________________________________________________
Yes

No

Unknown__________________________________(DD-MM-YYYY)
Yes

No

Unknown__________________________________(DD-MM-YYYY)

Patient comorbidities
Did the patient have any of the following coexisting
disorders at time of suspected or confirmed
COVID-19? (check all that apply)

Please specify type of cancer

27-04-2020 13:50

Cardiovascular disease (e.g. coronary arterydisease, heart failure, arrhythmia)
Diabetes
AsthmaCOPD
Other chronic lung disease (NOT asthma/COPD)
Hypertension
CancerHistory 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 textNone__________________________________

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Please specify type of rheumatologic or connective
tissue disease__________________________________

Please specify patient coexisting disorder at time ofsuspected or confirmed COVID-19 infection?

__________________________________

At time of COVID-19 was the patient pregnant?
Number of weeks gestation

Yes

No

Unknown__________________________________At the time of COVID-19 was the patient post-partum(< 6 weeks)?

Yes

No

Smoking status of patient

Current smoker
Former smoker
Never smoked
Unknown

Does the patient currently use e-cigarettes or vape?

Yes

Unknown

No

Unknown

At the time of COVID-19 was the patient taking any of the following medications?
Yes - medication
continued

1

ACE inhibitor e.g. Benazepril,
Lisinopril, Ramipril

2

Angiotensin-receptor blocker
e.g. Candesartan, Losartan,
Irbesartan, Valsartan

3

Nonsteroidal anti-inflammatory
drug (NSAID) e.g. Diclofenac,
Ibuprofen

4

PDE5 inhibitor e.g. Sildenafil(Viagra)5

Other - free text
Please specify other medication patient was taking at
the time of COVID-19?

Yes - medication
stoppedNo__________________________________________

COVID-19 questions
Which signs and symptoms did the patient suffer fromat the time of COVID-19? (check all that apply)

27-04-2020 13:50

Unknown

GeneralCardiorespiratory
Neurological
ENT
Gastrointestinal
None
Other - free text

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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
NauseaDiarrhoea

Please specify which signs and symptoms the patient
suffered from at the time of COVID-19?

Have the symptoms resolved?
Number of days of symptoms from COVID-19?

__________________________________________YesNo

Not applicable__________________________________(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)?

Yes

No

Unknown

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Region of hospital

Region of hospital

Was the patient hospitalized?
Region of hospital

Did the patient participate in the UK Governmentshielding protection scheme?
Region of hospital

Length of stay

What was the maximum level of care required during
the illness? (check all that apply)

Please specify the maximum level of care required
during the illness?

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
WessexSouth West Peninsula
North ThamesSouth London
North West London
Northern Ireland
ScotlandWales__________________________________
Yes

No

Unknown

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
WessexSouth West Peninsula
North ThamesSouth London
North West London
Northern Ireland
Scotland
Wales
Yes

No

____________________________________________________________________(days)
Did not require supplemental oxygen
Required oxygen by mask or nasal prongs
Required oxygen by non-invasive ventilation orhigh flow oxygen devices
Required intubation and mechanical ventilation
Required ECMO
Ventilation required, but type unknown
Interventions unknown
Other - free text__________________________________________

Did the patient have any immediate complications?

Yes

No

Unknown

Did the patient have any dermatologicalcomplications?

Yes

No

Unknown

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Please specify dermatological complications?
__________________________________________
What other complications did the patient suffer from?
(check all that apply)

Please specify what other complications the patient
suffered from?

Viral pneumonitis
Bacterial pneumonia
Acute Respiratory Distress Syndrome
Pneumothorax
Pleural effusion
Cryptogenic organizing pneumonia (COP)
Bronchiolitis
Meningitis or Encephalitis
SeizureStroke 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 severity of Acute Respiratory DistressSyndrome

Mild
Moderate
SevereUnknown

What treatment (including investigational therapy)
was commenced for COVID-19? (check all that apply)

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?

__________________________________________

Blood counts

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Lymphocyte countLymphocyte date

Neutrophil count

Neutrophil date

Neutrophil/lymphocyte ratio

WCC

WCC date

CRP

CRP date

Platelet countPlatelet count date__________________________________(one decimal place required e.g. 6.0)__________________________________(DD-MM-YYYY)__________________________________(one decimal place required e.g. 6.0)__________________________________(DD-MM-YYYY)____________________________________________________________________(one decimal place required e.g. 6.0)__________________________________(DD-MM-YYYY)__________________________________(one decimal place required e.g. 6.0)__________________________________(DD-MM-YYYY)__________________________________(one decimal place required e.g. 6.0)__________________________________(DD-MM-YYYY)

Clinical outcome
What was the clinical outcome?

Death date. If exact date not known, please give
most accurate estimate.

Death
RecoveryAny chronic complication__________________________________

Recorded cause of death__________________________________________

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Please specify any chronic complication__________________________________________

Other registries
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)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)

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PsoReg (Sweden)
Registry of Slovenian Psoriasis Patients (Slovenia)
SDNTT (Switzerland)
Other - free text
No
Please specify registry name and country

Do you also enter data into any of the following
COVID-19 registries?

Please specify what other COVID-19 registry you enter
data into?

__________________________________
SECURE-AD
AAD COVID-19 Dermatology Registry
Other - free textNone__________________________________

Email updatesWould you like to receive email updates on this, and future studies? We will not use this email for any other purpose,and you can opt out at any time by contacting us as at psoprotect@kcl.ac.uk. Your email contact will be stored safely
and will not be provided to any other third parties.
Yes

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No

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