Form 6 Attachment 7 Form 5a Current Symptoms

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 OMB Number 0925‐XXXX 
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CEIRS Human Influenza Surveillance Study
Form 5A: Current Symptoms
1. Is this subject considered to be exhibiting influenza like illness (ILI)?

□ No

2. If Yes, date of illness onset? __ __ / __ __ / __ __ __
__ (Note: must be within 7 days of ED presentation)

□ Yes □ Unknown

3. How many days has the subject had symptoms for? ______ days
(Note: asymptomatic subject should be 0 days of ED presentation)
4. Ask the subject to think about their symptoms within the past 7 days. Have they experienced any:
a. Cough?
i. If Yes, did they cough up sputum?
b. Shortness of breath?
c.

Sinus pain?

d. Nasal congestion/rhinorrhea?
e. Wheezing?
f.

Sore throat?

g. Fever?
i. If Yes, was it recorded?

□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No

□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown

□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No

□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown

ii. If recorded, the temperature was: ______ C
h. Fatigue?
i. If Yes, have they been able to get out of bed?
i.

Chest pain?
i. If Yes, does their chest hurt when they breathe?

j.

Chills?

k.

Body aches?

l.

Headache?

m. Loss of appetite?
n. Nausea/Vomiting?
o. Diarrhea?
p. Stomach pain?
q. Conjunctivitis?
r.

Other symptoms?

i. If Yes, specify other symptoms:_____________________________________________
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Form 5A: Current Symptoms

Version 2.0
01/05/2015