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Chief Complaints
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Chief Complaints Comments
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SUBJECTIVE
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Respiratory Illness Screening, Fever present
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Respiratory Illness Symptoms
• • •
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Additional Comments
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Travel to a high risk respiratory illness region
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Close contact w/ person(s) w/ known communicable illness
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Additional comments
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Travel/Close contact occur within 14 days of symptom onset
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Are you pregnant?
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Are you breast-feeding?
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ROS:
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Date and time of exam:
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Examined by:
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General Exam:
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RESP:
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PSYCH:
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Medical History:
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Surgical History:
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Hospitalization History:
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Family History:
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Social History:
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Medications:
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Allergies:
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OBJECTIVE
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PROCEDURE
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Indication (diagnosis)
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Consent Obtained and signed
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