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Experiencing shortness of breath or double breathing?
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Abdominal Pain
|
|
Chest Pain
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Extreme Fatigue or Ill Feelings
|
|
Rash
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Strange Sound when Breathing In/Out
|
|
Unintentional Weight Loss
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Urinating once or less <24 Hrs
|
|
Vomiting or Severe Nausea
|
Length of Present Illness in Days
|
|
Cough
|
Fever or Chills
|
|
Body Aches
|
New Multiple Select
• • •
|
|
Temperature taken with thermometer
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Type of thermometer used
|
|
Highest Temperature
|
Did you get Flu Vaccine this year?
|
|
Recent sick contact
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Smoke cigarettes or another tobacco
|
|
Traveled Out of State (3 Weeks)
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Tried treatment for current symptoms
|
|
Immunosuppressive condition
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Medical Condition
• • •
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Other information gathered/shared
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