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ILI Phone Follow Up/Check-In

Please complete this form daily by noon while you are ill, as a follow up to your visit to the Torrey Health Center and your diagnosis of Influenza-like Illness (ILI).   This form will help us coordinate your care in the most effective and efficient way.

If you have health concerns when the Torrey Health Center is closed, call x5555 anytime and you will be assisted.

Student Name

Residence hall and room number

Date of birth

Cell phone

Temperature

Please give the current time:
Have you had a fever in the last 24 hours at any time?
yes no

Your current temperature:

Time of most recent dose of fever medication

Are you feeling better, worse or the same as yesterday?

Better

Worse

Same

Do you have any symptoms of more severe illness? Check any that apply.

Fever is over 101 degrees and lasts for 5 or more days
Severe headache
Difficulty breathing or shortness of breath
Abdominal Pain
Stiff neck (unable to flex neck to chest)
Ear or facial pain
Sore throat so severe that swallowing is impaired or creating an inability to open mouth fully
Confusion or any change in level of consciousness
Severe or persistent vomiting
Diarrhea that is bloody
Flu-like symptoms improved but then return with fever and worse cough

Do you have everything you need?

Yes
No

If no, what do you need?



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