First name (given name) of reporter* must provide value
Last name (family name) of reporter* must provide value
Email address of reporter (institution email preferred)* must provide value
Professional title of reporter* must provide value
Dermatologist
Other Physician
Podiatrist
Physician Assistant
Nurse Practitioner
Nurse
Other
Other professional title:* must provide value
Hospital or clinic name* must provide value
Hospital or clinic country * must provide value
United States Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Other
Other country:* must provide value
Hospital or clinic state* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Choose Not to Answer
What is the patient's age in years?* must provide value
Patient's country of residence* must provide value
United States Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Unknown Choose not to answer Other
Other:* must provide value
Patient's U.S. state of residence * must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
What was the patient's assigned sex at birth?* must provide value
Female
Male
Unknown
Other
Other assigned sex:* must provide value
The option "
Patient's race/ethnicity* must provide value
White
Black - African
Afro - Caribbean
African American
American Indian / Alaska Native
Asian American
Asian-Chinese
South Asian (India, Pakistan, Sri Lanka, Nepal, Bhutan, Bangladesh)
Asian-other (Korea, China, north of Huai River)
Japanese
Hispanic or Latino
Native Hawaiian / Pacific Islander
Unknown
Other
Other race/ethnicity:* must provide value
Is the patient hispanic/latino?* must provide value
Yes
No
Don't know
Did this patient receive a COVID-19 vaccine? Yes
No
In which month did the patient receive the first dose of the COVID-19 vaccine?* must provide value
January February March April May June July August September October November December Don't Know
In which year did the patient receive the first dose of the COVID-19 vaccine?* must provide value
2020 2021 2022 Don't Know
Did the patient receive a second dose of the COVID-19 vaccine?* must provide value
Yes
No
In which month did the patient receive the second dose of the COVID-19 vaccine?* must provide value
January February March April May June July August September October November December Don't Know
In which year did the patient receive the second dose of the COVID-19 vaccine?* must provide value
2020 2021 2022 Don't Know
Why did the patient not receive the second vaccine dose?* must provide value
The patient is planning on receiving the second dose at the appropriate time interval which has not yet occurred
Vaccine only scheduled for one dose
Second dose held due to side effects from first vaccine dose
Other
Why was the second vaccine dose held?* must provide value
What was the other reason the patient did not receive the second vaccine dose?
Which brand of vaccine did the patient receive? * must provide value
Moderna Pfizer/BioNTech AstraZeneca/Oxford Johnson and Johnson Novavax CureVac Medicago Don't Know Other
Which other brand of the vaccine did the patient receive?
Are you reporting a dermatologic manifestation of a COVID-19 vaccine?* must provide value
Yes
No
Did this patient previously have COVID-19 prior to receiving the vaccine?* must provide value
No
Yes, SARS-CoV-2 PCR positive
Yes, SARS-CoV-2 antibody positive
Yes, SARS-CoV-2 antigen positive
Yes, laboratory positive but test type unknown
Yes, clinical suspicion only
Don't Know
Did the patient develop a cutaneous reaction to the first, second, or both vaccine doses?* must provide value
First dose
Second dose
Both doses (two separate reactions)
Was the cutaneous reaction for both vaccine doses the same?* must provide value
Yes
No
Was the cutaneous reaction for both vaccine doses of the same magnitude?* must provide value
Larger reaction for the first dose
Larger reaction for the second dose
Similar reactions for both doses
Don't know
How many days after the first dose of the COVID-19 vaccine did the patient develop a skin finding?* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop a skin finding?* must provide value
For how many days total did the patient have or has continued to have the reported dermatologic finding to the first vaccine dose?* must provide value
For how many days total did the patient have or has continued to have the reported dermatologic finding to the second vaccine dose?* must provide value
Please review the following images to aid in selecting the morphology of the vaccine cutaneous reaction What were the observed skin symptoms after the first vaccine dose? Select all that apply* must provide value
Local site reaction: swelling
Local site reaction: redness
Local site reaction: pain
Morbilliform rash
Vesicular rash
Contact dermatitis
Delayed hypersensitivity - local at vaccine site
Delayed hypersensitivity - larger than vaccine site
Urticaria (beyond injection site, including generalized)
Angioedema
Pruritus (itching)
Vasculitis
Alopecia
Filler reaction
Reaction in breast-fed infant
Livedo reticularis
Pernio/chilblains ("Covid toes")
Erythromelalgia (hands, feet, or face with pain/redness/swelling)
Erythema multiforme
Pityriasis rosea
Petechiae
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome
Acute generalized exanthematous pustulosis (AGEP)
Zoster (VZV)
New dermatologic condition (ie. dermatomyositis, lupus, scleroderma, pityriasis rosea, lichen planus, pemphigus, etc)
Flare of existing dermatologic condition (ie. psoriasis, atopic dermatitis, lupus, flare of chronic urticaria, HSV reactivation etc)
Other
What were the other skin symptoms?* must provide value
What is the age in months of the breastfed infant?
Please confirm above that all patient characteristics are for the person who received the COVID-19 vaccine (ie. the person breastfeeding)
* must provide value
What is the sex of the infant?* must provide value
Female
Male
Unknown
Other
What was the morphology of the infant's rash? Which body sites did it affect?* must provide value
Do you know how many days after the patient received the first dose of the COVID-19 vaccine the skin finding started?* must provide value
Yes
No
How many days after the first dose of the COVID-19 vaccine did the patient develop the local site reaction ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop the morbilliform rash ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop the vesicular rash ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop contact dermatitis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop the delayed hypersensitivity rash?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop the erythromelalgia ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop the urticarial rash?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop angioedema ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop pruritius (itching) ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop vasculitis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop alopecia ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop a filler reaction ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient's infant develop a rash in a breast-fed infant ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop livedo reticularis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop pernio/chilblains ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop erythema multiforme ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop pityriasis rosea ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop petechiae ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop DRESS syndrome ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop AGEP ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop Zoster (VZV) ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop a new dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop a flare of an existing dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the first dose of the COVID-19 vaccine did the patient develop an "other" dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
Is the patient's dermatologic reaction to the first vaccine dose still present at the time of this report?* must provide value
Yes
No
For how many days total did the patient have or has continued to have the local site reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the morbilliform rash to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the vesicular rash to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the contact dermatitis to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the delayed hypersensitivity to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the erythromelalgia to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the urticarial rash to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the angioedema to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the pruritus (itching) Â to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the vasculitis  to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the alopecia to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the filler reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the dermatologic reaction in a breastfed infant to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the livedo reticularis to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the pernio/chilblains reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the erythema multiforme reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the pityriasis rosea to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the petechiae to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the DRESS reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the AGEP reaction to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have Zoster (VZV) to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the new dermatologic condition to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the flare of the existing dermatologic condition to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the "Other" dermatologic condition to the first vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
Which new dermatologic condition did the patient develop? Select all that apply* must provide value
Alopecia areata
Atopic dermatitis
Bullous pemphigoid
Contact dermatitis
Cutaneous vasculitis
Dermatitis herpetiformis
Epidermolysis bullosa acquisita
Erythema nodosum
Granuloma annulare
Herpes simplex (HSV)
Herpes zoster (VZV)
Hidradenitis suppurativa
Lichen planus
Lichen sclerosus
Linear IgA disease
Lupus - systemic lupus erythematosus
Lupus - discoid lupus erythematosus
Lupus - other cutaneous lupus
Morphea
Pemphigus vulgaris
Pityriasis rosea
Psoriasis
Sarcoidosis
Scleroderma
Vitiligo
Other
What was the other new dermatologic condition?
Which flare of an existing dermatologic condition did the patient develop? Select all that apply* must provide value
Alopecia areata
Atopic dermatitis
Bullous pemphigoid
Contact dermatitis
Chronic urticaria
Cutaneous vasculitis
Dermatitis herpetiformis
Epidermolysis bullosa acquisita
Erythema nodosum
Granuloma annulare
Herpes simplex (HSV)
Herpes zoster (VZV)
Hidradenitis suppurativa
Lichen planus
Lichen sclerosus
Linear IgA disease
Lupus - systemic lupus erythematosus
Lupus - discoid lupus erythematosus
Lupus - other cutaneous lupus
Morphea
Pemphigus vulgaris
Pityriasis rosea
Psoriasis
Sarcoidosis
Scleroderma
Vitiligo
Other
What was the other dermatologic condition?
Where on the patient's body did the dermatologic reaction to the first vaccine dose occur? * must provide value
Face
Oral mucosa
Nails
Hair
Head
Neck
Vaccinated arm
Non-vaccinated arm
Hand
Chest
Abdomen
Back
Genitals
Buttocks
Leg
Foot
Did the patient develop any systemic symptoms after the first Covid-19 vaccine?* must provide value
Yes
No
What were the observed systemic symptoms after the first dose? Select all that apply* must provide value
Anaphylaxis (>1 of urticaria, throat or tongue swelling, shortness of breath, vomiting, lightheadedness, low blood pressure)
Fever
Chills
Headache
Myalgia (localized to injection arm or generalized)
Arthralgia
Fatigue
Nausea
Vomiting
Diarrhea
Lymphadenopathy
Bells palsy
Syncope/Vasovagal
Other
What were the other systemic symptoms?* must provide value
Please review the following images to aid in selecting the morphology of the cutaneous vaccine reaction What were the observed skin symptoms after the second vaccine dose? Select all that apply* must provide value
Local site reaction: swelling
Local site reaction: redness
Local site reaction: pain
Morbilliform rash
Vesicular rash
Contact dermatitis
Delayed hypersensitivity - local at vaccine site
Delayed hypersensitivity - larger than vaccine site
Urticaria (beyond injection site, including generalized)
Angioedema
Pruritus (itching)
Vasculitis
Alopecia
Filler reaction
Reaction in breast-fed infant
Livedo reticularis
Pernio/chilblains ("Covid toes")
Erythromelalgia (hands, feet, or face with pain/redness/swelling)
Erythema multiforme
Pityriasis rosea
Petechiae
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome
Acute generalized exanthematous pustulosis (AGEP)
Zoster (VZV)
New dermatologic condition (ie. dermatomyositis, lupus, scleroderma, pityriasis rosea, lichen planus, pemphigus, etc)
Flare of existing dermatologic condition (ie. psoriasis, atopic dermatitis, lupus, flare of chronic urticaria, HSV reactivation etc)
Other
What were the other skin symptoms?* must provide value
Do you know how many days after the patient received the second dose of the COVID-19 vaccine the skin finding started?* must provide value
Yes
No
How many days after the second dose of the COVID-19 vaccine did the patient develop the local site reaction ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop the morbilliform rash ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop the vesicular rash ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop contact dermatitis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop the delayed hypersensitivity rash?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop the erythromelalgia  rash?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop the urticarial rash?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop angioedema ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop pruritius (itching) ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop vasculitis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop alopecia ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop a filler reaction ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient's infant develop a skin rash in a breast-fed infant ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop livedo reticularis ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop pernio/chilblains ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop erythema multiforme ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop pityriasis rosea ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop petechiae ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop DRESS syndrome ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop AGEP ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop Zoster (VZV) ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop a new dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop a flare of an existing dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
How many days after the second dose of the COVID-19 vaccine did the patient develop an "other" dermatologic condition ?
Please enter "0" days if the reaction occurred < 24 hours after vaccine administration
* must provide value
Is the patient's dermatologic reaction to the second vaccine dose still present at the time of this report?* must provide value
Yes
No
For how many days total did the patient have or has continued to have the local site reaction to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the morbilliform rash to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the vesicular rash to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the contact dermatitis to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the delayed hypersensitivity to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the erythromelalgia to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the urticarial rash to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the angioedema to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the pruritus (itching) Â to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the vasculitis  to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the alopecia to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the filler reaction to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the dermatologic reaction in a breastfed infant to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the livedo reticularis to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the pernio/chilblains reaction to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the erythema multiforme to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have pityriasis rosea to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the petechiae to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the DRESS reaction to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the AGEP reaction to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the Zoster (VZV)Â to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the new dermatologic condition to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the flare of the existing dermatologic condition to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
For how many days total did the patient have or has continued to have the "Other" dermatologic condition to the second vaccine dose?
If the dermatologic conditon is ongoing please report the duration up to the time of this report
* must provide value
Which new dermatologic condition did the patient develop? Select all that apply* must provide value
Alopecia areata
Atopic dermatitis
Bullous pemphigoid
Contact dermatitis
Cutaneous vasculitis
Dermatitis herpetiformis
Epidermolysis bullosa acquisita
Erythema nodosum
Granuloma annulare
Herpes simplex (HSV)
Herpes zoster (VZV)
Hidradenitis suppurativa
Lichen planus
Lichen sclerosus
Linear IgA disease
Lupus - systemic lupus erythematosus
Lupus - discoid lupus erythematosus
Lupus - other cutaneous lupus
Morphea
Pemphigus vulgaris
Pityriasis rosea
Psoriasis
Sarcoidosis
Scleroderma
Vitiligo
Other
What was the other new dermatologic condition?
Which flare of an existing dermatologic condition did the patient develop? Select all that apply* must provide value
Alopecia areata
Atopic dermatitis
Bullous pemphigoid
Contact dermatitis
Chronic urticaria
Cutaneous vasculitis
Dermatitis herpetiformis
Epidermolysis bullosa acquisita
Erythema nodosum
Granuloma annulare
Herpes simplex (HSV)
Herpes zoster (VZV)
Hidradenitis suppurativa
Lichen planus
Lichen sclerosus
Linear IgA disease
Lupus - systemic lupus erythematosus
Lupus - discoid lupus erythematosus
Lupus - other cutaneous lupus
Morphea
Pemphigus vulgaris
Pityriasis rosea
Psoriasis
Sarcoidosis
Scleroderma
Vitiligo
Other
What was the other dermatologic condition?
Where on the patient's body did the dermatologic reaction to the second vaccine dose occur? * must provide value
Face
Oral mucosa
Nails
Hair
Head
Neck
Vaccinated arm
Non-vaccinated arm
Hand
Chest
Abdomen
Back
Genitals
Buttocks
Leg
Foot
Did the patient develop any systemic symptoms after the second Covid-19 vaccine?* must provide value
Yes
No
What were the observed systemic symptoms after the second dose? Select all that apply* must provide value
Anaphylaxis (>1 of urticaria, throat or tongue swelling, shortness of breath, vomiting, lightheadedness, low blood pressure)
Fever
Chills
Headache
Myalgia (localized to injection arm or generalized)
Arthralgia
Fatigue
Nausea
Vomiting
Diarrhea
Lymphadenopathy
Bells palsy
Syncope/Vasovagal
Other
What were the other systemic symptoms?* must provide value
Do you have a photo of the skin finding that you would be willing to share?* must provide value
Yes
No
Was a biopsy of the vaccine dermatologic reaction performed?* must provide value
Biopsy not performed
Yes biopsy performed for vaccine dermatologic reaction to first dose
Yes biopsy performed for vaccine dermatologic reaction to second dose
Yes biopsy performed for vaccine dermatologic reaction to both doses
Don't know
Please enter the biopsy report:
Was the patient given treatment for the vaccine skin reaction?* must provide value
No treatments given
Oral anti-histamine
Epinephrine injection
Topical steroids
Systemic steroids
NSAID
Acetaminophen
Antibiotics
Valacyclovir/Acyclovir
Lisinopril
Don't Know
Other
What was the other treatment for the vaccine skin reaction?* must provide value
Does this patient have a history of a vaccine allergic reaction? * must provide value
No
Yes - Local site reaction
Yes - Anaphylaxis
Yes - Urticaria
Yes - Other Reaction
Don't know
Please describe the prior vaccine allergic reaction:* must provide value
Does this patient have a history of an injectable medication allergic reaction? * must provide value
No
Yes - Local site reaction
Yes - Anaphylaxis
Yes - Urticaria
Yes - Other Reaction
Don't know
Please describe the prior injectable medication allergic reaction:* must provide value
[Optional] Please use this space to describe the dermatology-related COVID-19 vaccine reaction further if not fully captured in the fields above
Did the patient have new skin, nail, hair, mucous membrane or other dermatologic changes in the setting of possible or confirmed Covid-19?* must provide value
Yes
No
When did this patient develop a COVID-19 dermatologic manifestation in relation to receiving a COVID-19 vaccine?* must provide value
Vaccine occurred after COVID-19 dermatologic manifestation began
Vaccine occurred before COVID-19 dermatologic manifestation began
Vaccine occurred at the same time as the COVID-19 dermatologic manifestation
Don't know
Do you have a photo of the dermatologic condition?* must provide value
Yes
No
Was a biopsy of the Covid-19 dermatologic manifestation obtained?* must provide value
Yes
No
What did the pathology report show? Please put "NA" if the report is unavailable. * must provide value
Which dermatologic condition(s) were associated with the Covid-19 infection? Mark all that apply. * must provide value
Skin changes (rash, pernio/chilblains, skin pain/burning, etc)
Edema
Mucous membrane changes
Hair changes
Nail changes
Other dermatologic change
Did the patient have telogen effluvium? Yes
No
Which site did the edema involve? Mark all that apply. * must provide value
Periorbital edema
Other facial edema
Upper extremity edema
Lower extremity edema
Genital edema
Other
Other site of edema:* must provide value
Which mucous membranes were involved? Mark all that apply. * must provide value
Oral mucosa
Nasal mucosa
Ocular mucosa
Vaginal mucosa
Urethral mucosa
Anal mucosa
The option "
What were the ocular findings? Mark all that apply. * must provide value
Yes eye findings but unsure of categorization
Conjunctivitis (conjunctival inflammation)
Chemosis (swelling of conjunctiva)
Secretions (eye discharge)
Conjunctival hyperemia (dilation and redness of conjunctival vessels)
Epiphora (excessive eye watering)
Other
Other ocular finding:* must provide value
Please describe the observed mucous membrane changes. In your clinical opinion, were the mucous membrane changes related to Covid-19 itself, medications the patient received, or another medical condition?* must provide value
Please describe the observed hair changes. In your clinical opinion, were the hair changes related to Covid-19 itself, medications the patient received, or another medical condition?* must provide value
Please describe the observed nail changes. In your clinical opinion, were the nail changes related to Covid-19 itself, medications the patient received, or another medical condition?* must provide value
Please describe any other dermatologic changes. In your clinical opinion, were the changes related to Covid-19 itself, medications the patient received, or another medical condition?* must provide value
When did the skin findings start in relation to Covid symptoms?* must provide value
Before Covid symptoms started
After Covid symptoms started
At the same time as Covid symptoms
Patient never developed any other Covid symptoms except skin findings
Don't know
Do you know how many days before Covid symptoms started the skin lesion developed?* must provide value
Yes
No
How many days before Covid symptoms started did the rash develop?* must provide value
Do you know how many days after Covid symptoms started the skin lesion developed?* must provide value
Yes
No
How many days after Covid symptoms started did the rash develop?* must provide value
When did the skin findings start in relation to Covid treatment?* must provide value
Before Covid treatment started
After Covid treatment started
At the same time Covid treatment started
Not Applicable
Don't know
Have the patient's skin findings resolved at the time of this report?* must provide value
Yes
No
Don't know
Do you know how long the patient had the skin findings?* must provide value
Yes
No
For how many days did the patient have the skin findings?* must provide value
Did the patient have any skin symptoms?* must provide value
Asymptomatic
Pain or Burning
Pruritus
Cold intolerance
Don't know
The option "
What is the morphology of the skin findings? Mark all that apply. Please see below for example images of rash morphology.
* must provide value
Morbilliform rash
Urticarial eruption
Dengue-like rash
Vesicular eruption
Livedo reticularis-like rash
Retiform purpura
Grovers-like rash
Papulosquamous rash
Bullous eruption
Erythroderma
Pustular rash
Macular erythema
Acrocyanosis
Pernio (Chilblains)
Acral desquamation
Pressure injury
Palpable purpura / vasculitis
Petechiae
Erythema nodosum
Acneiform
Miliaria rubra
Livedo racemosa
Kawasaki-like/Multi-system inflammatory syndrome (MIS-C)
Multisystem Inflammatory Syndrome in Adults (MIS-A)
Not applicable
Don't know
Other
Please view the images below to assist you in determining rash morphology. Other morphology* must provide value
Does this patient have a history of pernio/chilblains prior to the start of the Covid-19 pandemic?* must provide value
Yes
No
Don't know
Which type of pernio/chilblains case are you reporting?* must provide value
First instance of pernio for patient
Pernio that started with an initial Covid-19 wave, resolved, and then recurred
Don't know
In which month and year did the pernio lesions first start?* must provide value
January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020 January 2021 February 2021 March 2021 April 2021 May 2021 June 2021 July 2021 August 2021 September 2021 October 2021 November 2021 December 2021
In which month and year did the pernio lesions clear?* must provide value
January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020 January 2021 February 2021 March 2021 April 2021 May 2021 June 2021 July 2021 August 2021 September 2021 October 2021 November 2021 December 2021
In which month and year did the pernio lesions start again?* must provide value
January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020 January 2021 February 2021 March 2021 April 2021 May 2021 June 2021 July 2021 August 2021 September 2021 October 2021 November 2021 December 2021
Was the pressure ulcer likely due to the patient being positioned prone? * must provide value
Yes
No
Don't know
What areas of the body do the skin findings involve? Mark all that apply. * must provide value
Face
Head
Neck
Chest
Abdomen
Back
Arm
Hand
Genitals
Buttocks
Leg
Foot
Entire body
Other
Other area of the body:* must provide value
Were there any additional labs obtained for this COVID-19 related dermatologic condition that you would like to report?* must provide value
Yes
No
Please check the labs that were obtained for the COVID-19 dermatologic condition that you would like to report* must provide value
Hemoglobin
White blood cell count
Platelet count
Antinuclear antibodies (ANA)
Rheumatoid factor (RF)
Cold agglutinins
Cryoglobulins
Complement (C3/C4/CH50)
C-Reactive Protein (CRP)
Erythrocyte sedimentation rate (ESR)
D-Dimer
Fibrinogen
Anticardiolipin antibodies (aCL)
Anti-beta2-glycoprotein (GP) antibodies
Lupus anticoagulant (LA)
Other
What is the other lab and lab value you would like to report?* must provide value
In your clinical opinion, what is the likely etiology of the dermatologic findings?* must provide value
Likely related to Covid virus itself
Likely related to a drug given for Covid treatment
Likely related to a drug given for a condition other than Covid
Likely related to another virus
Likely related to a post-viral rash
Unsure
Other
Other etiology of the skin findings:* must provide value
Would you be willing to be contacted about this patient if we need further clarification about this case?* must provide value
Yes
No
(Optional): Please describe the dermatology-related Covid-19 case in 1-5 sentences:
Does this patient have a pre-existing dermatologic condition?* must provide value
Yes
No
Unknown
What is the patient's primary existing dermatologic condition?* must provide value
Acne vulgaris Allergic contact dermatitis Alopecia - alopecia areata Alopecia - scarring Alopecia - androgenetic Alopecia - other Atopic dermatitis Basal cell carcinoma Bullous pemphigoid Cellulitis Contact dermatitis Dermatomyositis Erythema nodosum Erythrasma Folliculitis Granuloma annulare Herpes simplex Herpes simplex Herpes zoster (shingles) Hidradenitis suppurativa Urticaria/Hives Kaposi's sarcoma Keloids Leprosy Lichen planus Lichen simplex chronicus Lupus - systemic lupus erythematosus Lupus - discoid lupus erythematosus Lupus - other cutaneous lupus Melanoma Melasma Merkel cell carcinoma Pemphigus vulgaris Perioral dermatitis Pityriasis rosea Psoriasis Psoriatic arthritis Raynaud's phenomenon Rosacea Sarcoidosis Scabies Scleroderma Seborrheic dermatitis Squamous cell carcinoma Stasis dermatitis Syphilis Tinea Vasculitis, cutaneous Vitiligo Xeroderma pigmentosum Other
Other primary existing dermatologic condition:* must provide value
What was the symptom activity of the patient's dermatologic disease at the time of Covid-19 symptom onset (or Covid-19 diagnosis if asymptomatic)?* must provide value
Remission
Minimal or low disease activity
Moderate disease activity
Severe or high disease activity
Unknown
Did the patient's dermatologic disease change at the time of Covid-19 symptom onset (or Covid-19 diagnosis if asymptomatic)?* must provide value
Worsened
Improved
Stayed the same
Unknown
The option "
Which medications is the patient taking for their dermatologic condition? Mark all that apply. * must provide value
None
Antimalarials (including hydroxychloroquine, chloroquine)
Azathioprine
CD-20 inhibitors (including rituximab, ofatumumab)
Cyclophosphamide
Cyclosporine
Doxycycline
Glucocorticoids (prednisone, methylprednisolone)
IL-1 inhibitors (including anakinra, canakinumab, rilonacept)
IL-12/23 inhibitors (including ustekinemab)
IL-23 inhibitors (including guselkumab, tildrakizumab, risankizumab)
IL-17 inhibitors (including secukinumab, ixekizumab)
IL-6 inhibitors (including tocilizumab, sarilumab)
Isotretinoin
IVIG
JAK inhibitors (including tofacitinib, baricitinib, upadacitinib)
Leflunomide
Methotrexate
Minocycline
Mycophenolate mofetil / mycophenolic acid
Spironolactone
Sulfasalazine
Tacrolimus (topical)
Tacrolimus (oral)
Thalidomide / lenalidomide
TNF-inhibitors (including infliximab, etanercept, adalimumab, golimumab, certolizumab, and biosimilars)
Topical steroid class II (ex. betamethasone, mometasone)
Topical steroids class I (ex. clobetasol)
Unknown
Other
Other medication for their dermatologic condition prior to Covid-19 diagnosis:* must provide value
The option "
In the 14 days before onset of Covid-19 illness did the patient have any of the following contacts?* must provide value
None (community acquired)
Close contact with a probable case of COVID-19 infection
Close contact with a laboratory confirmed case of COVID-19 infection
Presence in a healthcare facility where COVID-19 infections have been managed
Unknown
Other
Other Covid-19 contacts:* must provide value
Do you know the date of the patient's COVID-19 diagnosis?* must provide value
Yes
No
What was the date of the patient's COVID-19 diagnosis?* must provide value
Today M-D-Y
The option "
What kind of COVID-19 testing was performed? Please mark all that apply, including both antibody and PCR testing
* must provide value
Presumptive diagnosis based on symptoms only
PCR positive
Antibody positive
PCR negative
Antibody negative
Metagenomic testing
Laboratory assay positive, type unknown
Laboratory assay negative, type unknown
Unknown if a COVID-19 test was performed
Other
Which of the following antibodies were positive?* must provide value
Positive, but unknown which antibody
IgM positive and IgG positive
IgM positive, IgG negative
IgM negative, IgG positive
IgM positive, IgG unknown
IgM unknown, IgG positive
Other
Other positive antibody* must provide value
Which of the following antibodies were negative?* must provide value
Negative, but unknown which antibody
IgM negative and IgG negative
IgM negative, IgG unknown
IgM unknown, IgG negative
Other
Other negative antibody* must provide value
What type of antibody testing was performed?* must provide value
Abbott Laboratories
Becton Dickinson
Roche
DiaSorin
EUROIMMUN US Inc.
Wadsworth Center, New York State Department of Health
Bio-Rad Laboratories, Inc
Ortho-Clinical Diagnostics, Inc
Autobio Diagnostics Co. Ltd.
Chembio Diagnostic System, Inc
Cellex Inc.
Don't know
Other
Other antibody testing type: * must provide value
Other type of Covid-19 diagnosis:* must provide value
Are any of the following laboratory tests pending? (if yes, we may contact you about the results at a later date) None
COVID PCR testing
COVID antibody testing
The option "
Did the patient have any non-dermatologic COVID-19 symptoms?* must provide value
None (Asymptomatic)
Fever
Chills
Headache
Sore throat
Cough
Shortness of breath
Arthralgia
Myalgia
Chest pain
Abdominal pain
Diarrhea, vomiting or nausea
Rhinorrhea
Irritability/confusion
Malaise
Anosmia
Dysgeusia
Don't know
Other
Other non-dermatologic Covid-19 symptom:* must provide value
Do you know how much time elapsed (in days) between the patient's first non-dermatologic COVID-19 symptom and their PCR test? * must provide value
Yes
No
How many days after the non-dermatologic COVID-19 symptoms first started was PCR testing performed?* must provide value
Do you know how much time elapsed (in days) between the patient's first dermatologic COVID-19 symptom and their PCR test? * must provide value
Yes
No
How many days after the dermatologic COVID-19 symptoms first started was PCR testing performed?* must provide value
Do you know how much time elapsed (in days) between the patient's first non-dermatologic COVID-19 symptom and their antibody test? * must provide value
Yes
No
How many days after the non-dermatologic COVID-19 symptoms first started was antibody testing performed?* must provide value
Do you know how much time elapsed (in days) between the patient's first dermatologic COVID-19 symptom and their antibody test? * must provide value
Yes
No
How many days after the dermatologic COVID-19 symptoms first started was antibody testing performed?* must provide value
The option "
Was any COVID-19 specific treatment given? Please mark all that apply.* must provide value
No treatment except supportive care
Antibiotics
Remdesivir
Lopinavir/ritonavir
Anti-malarials (e.g. chloroquine, hydroxychloroquine)
IL-6 inhibitors (e.g. tocilizumab, sarilumab, siltuximab)
Bevacizumab
JAK inhibitors (e.g. tofacitinib, baricitinib, upadacitinib)
Serpin inhibitors
Ciclesonide
Glucocorticoids
IVIG
Plasma from recovered patients
Interferon
Don't know
Other
The option "
Which antibiotic was given? Please mark all that apply.* must provide value
Azithromycin
Doxycycline
Clarithromycin
Amoxicillin
Levofloxacin
Moxifloxacin
Ciprofloxacin
Ceftriaxone
Amoxicillin-clavulanate
Piperacillin-tazobactam
Cefepime
Ceftazidime
Meropenem
Imipenem
Vancomycin
Linezolid
Unknown antibiotic
Other antibiotic
Other:* must provide value
Was the patient hospitalized during COVID-19 illness?* must provide value
Yes
No
Don't know
What was the maximum level of care required during COIVD-19 infection?* must provide value
Did not require supplemental oxygen
Required supplemental oxygen
Required non-invasive ventilation or high flow oxygen devices
Required invasive mechanical ventilation or ECMO
Ventilation required, but type unknown
Don't know
The option "
Were there any COVID-19 complications?* must provide value
No known complications
Acute Respiratory Distress Syndrome or ARDS
Sepsis
Myocarditis or new heart failure
Concomitant or secondary infection (e.g. Influenza)
Acute Kidney Injury
Thrombotic event, unknown origin
DVT
Thrombotic stroke
Pulmonary embolism
Don't know
Other serious complication
Other serious complication:* must provide value
Did patient die of COVID-19 or other complications caused by or contributed to by COVID-19?* must provide value
Yes
No
Don't know
Have the patient's COVID-19 symptoms resolved at the time of this report?* must provide value
Yes
No
Don't know
Do you know approximately how many days the patient was symptomatic with COVID-19?* must provide value
Yes
No
Approximately how many days passed from COVID-19 symptom onset to resolution?* must provide value
Patient's smoking status * must provide value
Current smoker
Former smoker
Never smoked
Unknown smoking status
The option "
Does the patient have any of the following other medical conditions? Mark all that apply. * must provide value
None
Interstitial lung disease (e.g. NSIP, UIP, IPF)
Obstructive lung disease (COPD/asthma)
Other lung disease
Diabetes
Morbid obesity (BMI 40+)
Hypertension
Cardiovascular disease (coronary artery disease, congestive heart failure)
Pulmonary hypertension
Chronic renal insufficiency or end stage renal disease
Cancer
Organ transplant recipient
Immunodeficiency
Inflammatory bowel disease
Liver disease
Chronic neurological or neuromuscular disease
Trisomy 21
Psychiatric condition (e.g., schizophrenia, bipolar disorder)
Pregnancy
Post-partum (< 6 weeks)
Rheumatologic disease
Don't know
Other
Other co-morbid medical condition:* must provide value
Has this patient case been entered in any other COVID-related registry?* must provide value
None
PsoProtect
SECURE-Psoriasis
Atopic Dermatitis SECURE-AD Registry
Global Hidradenitis Suppurativa COVID-19 Registry
SECURE Alopecia
Vitiligo Group Registry
The French Society of Dermatology's Dermatologic Manifestations of COVID-19 Registry
PeDRA pediatric dermatology COVID-19 registry
Thank you for entering this patient with psoriasis! Please submit your case here, and then if you are able, please additionally consider entering this case into the psoriasis registry, as detailed below: Thank you for entering this patient with atopic dermatitis! Please submit your case here, and then if you are able please additionally consider entering this case into the atopic dermatitis registry, as detailed below: Thank you for entering this patient with hidradenitis suppurativa! Please submit your case here, and then if you are able, please additionally consider entering this case into the hidradenitis suppurativa registry, as detailed below: Thank you for entering this patient with alopecia! Please submit your case here, and then if you are able, please additionally consider entering this case into the COVID-19 alopecia registry, as detailed below: Thank you for entering this patient with pernio! Please submit your case here, and then if you are able, please additionally consider entering this case into the pediatric pernio registry, as detailed below:
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