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?