Name of treating physician
email address of treating physician
Is patient older than 89 years old?
Yes No
Age of patient at time of COVID-19 infection
Male Female Other
Race/Ethnicity
Native American/Canadian/Alsaska Native
Black/ African American
Arab
Western European
Native Australian
Hispanic/Latino
Eastern European
South Asian (Indian)
Asian
White
Other
Åland Islands Afghanistan Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Côte dIvoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Authority -Gaza, Judea and Samaria Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Ré union Romania Russian Federation Rwanda Saint Barthélemy Saint 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 Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Vietnam Virgin Islands, British Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
State or Territory of residence
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
No exposure
Active smoker
Passive exposure
Does patient have Asthma?
Yes No Unknown
Does patient take chronic or preventive treatment for asthma (inhaled steroids, montelukast, biologics)
Yes No Unknown
Has patient been hospitalized in the past year for asthma exccerbation?
Yes No Unknown
Does the patient used inhaled Beta-agonists (EG albuterol etc.) more than 2/week?
Yes No Unknown
Does the patient have Atopic dermatitis?
Yes No Unknown
Does the patient have Allergic rhinitis?
Yes No Unknown
Does the patient have food allergy?
Yes No Unknown
Does the patient suffer from any other chronic disease other than EOE/EGID?
Yes No
Type of EOE/EGID
Eosinophilic Esophagitis (EOE)
Eosinophilic Gastritis (EG)
Eosinophilic Enteritis (EE)
Eosinophilic Colitis (EC)
10^3/uL Not Done
10^3/uL Not Done
(gr/L) (gr/dL) Not Done
gr/L gr/dL Not Done
mm/h Not Done
mg/L
mg/dL
mg/%
Not Done
CRP Upper Limit of Normal
Global assessment of disease activity prior to COVID-19 exposure
Complete remission (clinically and, as much as known, also histologically)
Clinical remission (but, as much as known, histologically active)
Mild disease activity
Moderate disease activity
Severe disease activity
Longitudinal physician global assessment -
Type of last imaging prior to COVID-19 infection
US
MRE
CTE
Barium Swallow
Year of last imaging test
Year of last endoscopic assessment
Assessment of endoscopic severity
None
Mild
Moderate
Severe
Please describe endoscopic results
Please select current EOE/EGID medication (within 3 months of infection)
Dietary Elimitation
Swallowed Topical Steroids
Systemic Steroids
PPI
Azathioprine/6mp
Enteric Budesonide
Anti IL-5 (Mepolizumab, Reslizumab)
Anti IL-5 receptor (Benralizumab)
Dupilumab
Vedolizumab
Omalizumab
Anti Siglec-8 antibody
Montelukast
Cromolyn
Ketotifen
Other
Dietary Elimitation: What elimitation?
Was Dietary Elimitation undertaken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Dietary Elimitation stopped?
Swallowed Topical Steroids: Type of Steroid
Viscous budesonide
Jorveza
Fluticasone inhaler
Other
Were Swallowed Topical Steroids taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Swallowed Topical Steroids stopped?
Swallowed Topical Steroids: Dose (mg/dose)
Swallowed Topical Steroids: Number of Doses per day
Were Systemic Steroids taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Systemic Steroids stopped?
Systemic Steroids: Dose (mg/dose)
Systemic steroids: Number of doses per day
Were PPI taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was PPI stopped?
PPI: Number of doses per day
Was Azathioprine/6mp taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Azathioprine/6mp stopped?
Azathioprine/6mp: Dose (mg/dose)
Azathioprine/6mp: Number of doses per day
Was Enteric Budesonide taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Enteric Budesonide stopped?
Budeson: Number of doses per day
Was Anti IL-5 (Mepolizumab, Reslizumab) taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Anti IL-5 (Mepolizumab, Reslizumab) stopped?
Anti IL-5 (Mepolizumab, Reslizumab): Dose (mg/does)
Anti IL-5 (Mepolizumab, Reslizumab): Interval between doses (weeks)
Was Anti IL-5 receptor (Benralizumab) taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Anti IL-5 receptor (Benralizumab) stopped?
Anti IL-5 receptor (Benralizumab): Dose (mg/dose)
Anti IL-5 receptor (Benralizumab): Interval between doses (weeks)
Was Dupilumab taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Dupilumab stopped?
Dupilumab: Dose (mg/dose)
Dupilumab: Interval between doses (weeks)
Was Vedolizumab taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Vedolizumab stopped?
Vedolizumab: Dose (mg/dose)
Vedolizumab: Interval between doses (weeks)
Was Omalizumab taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Omalizumab stopped?
Omalizumab: Dose (mg/dose)
Omalizumab: Interval between doses (weeks)
Was Anti Siglec-8 antibody taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Anti Siglec-8 antibody stopped?
Anti Siglec-8 antibody: Dose (mg/dose)
Anti Siglec-8 antibody: Interval between doses (weeks)
Was Montelukast taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Montelukast stopped?
Montelukast: Dose (mg/dose)
Montelukast: Number of doses per day
Was Cromolyn taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Cromolyn stopped?
Cromolyn: Number of doses per day
Was Ketotifen taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was Ketotifen stopped?
Ketotifen: Dose (mg/dose)
Ketotifen: Number of doses per day
Was this treatment (other) taken at the time of the COVID-19 infection?
Yes No
How many weeks before the infection was this treatment (other) stopped?
Other: Number of doses per day
Has the patient ever had an esophageal dilation?
Yes No
Was an esophageal dilation performed during the last 3 months prior to COVID-19 infection?
Yes No
Does the patient currently have a feeding tube?
Yes No
Past EOE/EGID treatments (discontinued at least 3 months prior to infection)
Dietary Elimitation
Swallowed Topical Steroids
Systemic Steroids
PPI
Azathioprine/6mp
Enteric Budesonide
Anti IL-5 (Mepolizumab, Reslizumab)
Anti IL-5 receptor (Benralizumab)
Dupilumab
Vedolizumab
Omalizumab
Anti Siglec-8 antibody
Montelukast
Cromolyn
Ketotifen
Other
Was patient receiving any other medication not related to EOE/EGID
Yes No
The COVID-19 diagnosis was
Confirmed Suspected
Year of COVID-19 diagnosis
Why was this suspected case not confirmed by virology testing?
Patient weight (kg) closest to COVID-19 infection
Patient height (cm) closest to COVID-19 infection
Who was the index contagious case, if known
parent
spouse
child
work contact
travel out of the country of residence
neighbor
other
unknown
Presenting symptoms
Asymptomatic
Low fever (38°c-39°c)
Highest fever>39°c
Cough
Dyspnea
Runny nose
Other
Severity of COVID 19 infection
asymptomatic
mild
moderate
severe
unknown
COVID-19 related hospitalization
Yes No
Number of hospitalization days
Intensive Care Unit admission
Yes No
Yes No
Yes No
Total days from symptoms to clinical resolution of the infection
Were there residual symptoms related to COVID-19 at time of report?
Yes No
Did the patient receive any antiviral medication
Yes No Unknown
Name of antiviral medication
Did the infection induce a flare of the EOE/EGID?
Yes No Unknown
Mild Moderate Severe
Did you stop the EOE/EGID treatment because of the COVID-19 infection?
Yes No Unknown
Which EOE/EGID medication was stopped?
Was treatment re-started?
Yes
No
For how many weeks had the treatment been stopped?
Yes No
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