Form Approved
OMB No. 0920-XXXX
Exp. Date: XX/XX/XXXX
Week of:________________________________________________
Symptom |
Mon |
Tue |
Wed |
Thu |
Fri |
Sat |
Sun |
Notes |
Fever |
o |
o |
o |
o |
o |
o |
o |
|
Chills |
o |
o |
o |
o |
o |
o |
o |
|
Headache |
o |
o |
o |
o |
o |
o |
o |
|
Fatigue |
o |
o |
o |
o |
o |
o |
o |
|
Muscle aches |
o |
o |
o |
o |
o |
o |
o |
|
Joint pain |
o |
o |
o |
o |
o |
o |
o |
|
Back pain |
o |
o |
o |
o |
o |
o |
o |
|
Dizzy, lightheaded, or vertigo |
o |
o |
o |
o |
o |
o |
o |
|
Excessive sweating |
o |
o |
o |
o |
o |
o |
o |
|
Red eyes |
o |
o |
o |
o |
o |
o |
o |
|
Eye or retroorbital pain |
o |
o |
o |
o |
o |
o |
o |
|
Light sensitivity |
o |
o |
o |
o |
o |
o |
o |
|
Muscle weakness |
o |
o |
o |
o |
o |
o |
o |
|
Paralysis |
o |
o |
o |
o |
o |
o |
o |
|
Seizures |
o |
o |
o |
o |
o |
o |
o |
|
Stiff neck or neck pain |
o |
o |
o |
o |
o |
o |
o |
|
Confusion |
o |
o |
o |
o |
o |
o |
o |
|
Tremors |
o |
o |
o |
o |
o |
o |
o |
|
Numbness or tingling |
o |
o |
o |
o |
o |
o |
o |
|
Loss of appetite |
o |
o |
o |
o |
o |
o |
o |
|
Nausea |
o |
o |
o |
o |
o |
o |
o |
|
Vomiting |
o |
o |
o |
o |
o |
o |
o |
|
Diarrhea |
o |
o |
o |
o |
o |
o |
o |
|
Abdominal pain |
o |
o |
o |
o |
o |
o |
o |
|
Sore throat |
o |
o |
o |
o |
o |
o |
o |
|
Cough |
o |
o |
o |
o |
o |
o |
o |
|
Shortness of breath |
o |
o |
o |
o |
o |
o |
o |
|
Chest pain |
o |
o |
o |
o |
o |
o |
o |
|
Rash |
o |
o |
o |
o |
o |
o |
o |
|
Painful urination |
o |
o |
o |
o |
o |
o |
o |
|
Urinary incontinence |
o |
o |
o |
o |
o |
o |
o |
|
Difficulty emptying bladder |
o |
o |
o |
o |
o |
o |
o |
|
Vaginal discharge |
o |
o |
o |
o |
o |
o |
o |
|
Penile discharge |
o |
o |
o |
o |
o |
o |
o |
|
Painful ejaculation |
o |
o |
o |
o |
o |
o |
o |
|
Scrotal or testicular pain |
o |
o |
o |
o |
o |
o |
o |
|
Hemorrhage |
o |
o |
o |
o |
o |
o |
o |
|
Other |
o |
o |
o |
o |
o |
o |
o |
|
Other |
o |
o |
o |
o |
o |
o |
o |
|
CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Vahey, Grace (CDC/NCEZID/DFWED/ORPB) |
| File Modified | 0000-00-00 |
| File Created | 2024-10-29 |