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) |
| | |E - | |
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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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