Vulnerability Form
Please complete any that apply. (For example if you don't have a heart condition you do not need to answer any of those particular questions, only answer the questions to any condition you have)
 
Please add any condition that is not on this form in the free text at bottom of form. (the numbers to the left indicate level of risk (1=low to 3=high) and are there so I can score risk level once this form is complete)

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Name *
Date of Birth
MM
/
DD
/
YYYY
Weak Immune system? (excluding cancers) such as polymyalgia, rheumatoid arthritis, SLE, lupus?                                                       If yes please explain. If no then ignore question
1 point
Cancers
4 points
yes
1- Cancers sucessfully treated over 6 months ago
2- chemotherapy or XRT completed in the last 6 months
3- who are undergoing active chemotherapy or radiotherapy for lung cancer
3- Cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatmentf
3- People having immunotherapy or other continuing antibody treatments for cancer
3- People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
3- People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
Clear selection
Heart conditions
4 points
yes
1- Cardiac conditions such as previous heart attack with no ongoing problems
1- Controlled high BP, etc.
2- Angina (chest pain) on the flat or at rest (CCS Class III or IV) despite medication.
2- Poorly controlled blood pressure despite medication (grade 2 hypertension, BP 160-179/100-109 or higher.
2- Chronic heart disease, such as heart failure.
2- Heart valve disease that is severe and associated with symptoms (such as breathlessness or chest pain) despite medication.
2- Uncontrolled atrial fibrillation (HR > 100) especially if associated with reduced left ventricular function
2- Cardiomyopathy (any type) if you have symptoms such as breathlessness, or it limits your daily life, or you’ve been told you have problems with your heart function.
2- open heart surgery over 6 months ago
3- Heart transplant
3- Complex congenital heart disease
Clear selection
Respiratory Conditions
2 points
yes
1-Mild asthma that is well controlled is not at high risk.
1- Use of CPAP machine for Sleep Apnoea
2- Asthma requiring high-dose inhaled steroids alongside additional controller treatments for their asthma who have suffered 2 or more asthma exacerbations requiring oral steroids over the past year and continues to experience frequent asthma symptoms requiring use of their reliever medication.
2- COPD with additional risks such as older age or co-morbidities, those on oral maintenance corticosteroids, oxygen or those with a history of frequent exacerbations requiring oral steroids or antibiotics.
3- Severe asthma (hospital diagnosed in accordance with ATS/ERS guidelines) including those requiring biologic treatments, maintenance oral corticosteroids or other immunosuppressant.
3- Severe COPD,
3- Cystic fibrosis.
3- Emphysema
3- Confirmed occupational lung disease and
3- Pulmonary hypertension
3- Lung Transplant
Clear selection
Neurological disorders
yes
1- Mild multiple sclerosis only with sensory or visual changes.
1- Stable mild cerebral palsy (i.e. where they may walk a little awkwardly, but might not need any special help)
1- Treatment responsive mild Parkinson’s disease.
1- Well controlled, non-complex epilepsy.
1- Fibromyalgia / ME
1-Mild learning disabilities (assess risk associated with inability to follow IPC guidance such as hand washing).
2- Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis
2- Chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis, learning disability or moderate cerebral palsy (i.e. may need to use special equipment to be able to walk, or might not be able to walk at all or need lifelong care)
2- Learning disability or moderate cerebral palsy (.e. may need to use special equipment to be able to walk, or might not be able to walk at all or need lifelong care)
3- Multiple sclerosis with advanced disability (i.e. bulbar or respiratory compromise, or where they are on selected immunotherapies).
3- Conditions leading to respiratory or bulbar weakness such as complex epilepsy, severe cerebral palsy and kyphoscoliosis.
Clear selection
Renal Disorders
yes
1-Chronic Kidney Disease 1, 2 (and 3 A/B unless it falls into high/significant risk)
1- Patients less than 60 years who are generally well and whose disease has been stable for > 6 months who are on Hydroxychloroquine alone
2- AI disease affecting their CVS/Respiratory systems such as lung fibrosis
2- Non-autoimmune underlying co- morbidity of `respiratory/cardiovascular system, hypertension or diabetes mellitus
2- Stable chronic Kidney Disease (CKD) stage 3 or above with modest maintenance immunosuppression.
2- Previous adverse infectious complications of immunosuppression – e.g. those with recurrent CMV or chest infections
3- Renal or other organ transplant recipients with CKD
3- Those with End stage kidney disease (ESKD) receiving dialysis.
3- IV induction immunosuppressive medication for autoimmunedisease e.g. receiving cyclophosphamide/Euro lupus regimens or have received cytotoxic / rituximab / other biologic within the last 6 months.
3- Corticosteroid dose of > or = to prednisolone 20mg/day or 35mg/m2/day for more than 4 weeks within the last 6 months.
3- Prednisolone dose of > 5 mg/day, or >0.25mg/kg/day (or equivalent ) for > 4 weeks plus at least one other immunosuppressive medication within the last 6 months.
3- Current nephrotic range proteinuria or who have a history of frequently relapsing nephrotic syndrome.
3- Overall cumulative burden of immunosuppression (IS) is high over a number of years even if their current is in stable maintenance phase e.g. patients who have received repeated courses of cyclophosphamide/biologics/or repeated high dose corticosteroids.
3- Those with well controlled disease activity and no co-morbidity who are on single oral immunosuppressive drugs.
3- Those known to have low IgG levels even if not currently on immunosuppression.
3- B cell depleted despite completing biologic induction treatment more than 6 months previously.
3- Those in disease remission who remain on maintenance low dose prednisolone
Clear selection
Liver Disorders & Inflammatory bowel disease
yes
1- fatty liver disease
1- Haemochromatosis
2- Those on Ustekinumab, Vedolizumab, Methotrexate, Anti-TNF alpha monotherapy, Thiopurines, Calcineurin inhibitors, Janus kinase, combination therapy (in stable patients) and iimmunosuppressive biological trial medication.
2- Patients with decompensated liver cirrhosis
3- Liver transplant
Clear selection
Diabetes
yes
1-Diabetes controlled by diet or tablets with no diabetic complications
2- Diabetes well controlled on insulin and without diabetic complications
3- Diabetes controlled on insulin or diabetes with diabetic complications or poor glucose control
3- pancreas transplant
Clear selection
Other conditions
yes
1- coeliac disease
2- serious obesity- BMI over 40
3- multiple severe diseases of body systems
Clear selection
Please list any other condition or not already on this form that you thin might be relevant
Please add any medications that you are on
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