COVID-19 case reporting 

1.In which country do you work?
2.Are you reporting a case from a private or a public centre?
3.Your profession is:
4.Please enter a patient reference number from your clinic. The patient reference number can be used for submitting further details of the case at a later stage via email to (please specify). Please note that this reference number should not contain any patient identifiers.  
5.Please add your email address so we can contact you for further updates on this case
6.Was the COVID-19 infection in the patient confirmed with laboratory tests?
7.At what stage of the pregnancy did the patient have symptoms and was tested?
8.Which symptoms did the patient have (check all that apply)?
9.Was the patient hospitalized?
10.Are you aware of antiviral treatments used?
11.Did the patient recover?
12.How did the patient achieve pregnancy?
13.Please provide any relevant medical background history for the patient (what diseases did she suffer from?)
14.Where there any pregnancy complications (check all that apply)
15.What was the mode of delivery?
16.What was the gestational age at delivery (in weeks)?
17.Where there any neonatal complications? (check all that apply)
18.What was the birth weight of the newborn?
19.What were the APGAR scores at 1 minute?
20.What were the APGAR scores at 5 minutes?
21.Was the COVID-19 infection tested in the newborn?
22.What was the COVID-19 infection test result in the newborn? (Mark all that apply)
23.Please make any further comments with regards to this case
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