CDS-11, Patient Symptoms Line Listing (Respiratory Tract ...



|New Jersey Department of Health |PATIENT SYMPTOMS LINE LISTING |

|Infectious and Zoonotic Diseases Program |(Respiratory Tract Infection) |

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|Please check (X) those items that apply and complete requested information. |

Name |Staff |Resident |Onset Date |Wing |Room/Job |Age/Sex |Max. Temp. |Rales/Wheeze/Rhonchi |Cough (Dry/Productive) |Nasal Congestion |SOB/Resp. Distress |Sore Throat |Myalgia |Fatigue |Nausea/Vomit/Diarrhea |CXR

(Results) |Flu Vaccine Given? |Pneumococcal Vaccine Given? |Culture Done? |Hospitalized? |Admission Date |Discharge Date |Comments

(Note: Hospital Name; Dx; other significant clinical information; culture results, etc.) | |1 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |2 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |3 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |4 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |5 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |6 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |7 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |8 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |9 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |10 |      |   |   |   |   |   |   |   |   |   |   |   |   |   |   |   |      |   |   |   |   |   |   |      | |CDS-11 NOV 15

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