Upper Respiratory Infection Assessment
Please complete this assessment to help us evaluate your symptoms and risk factors for an upper respiratory infection.
Patient Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Age Group
*
Please Select
Under 18
18-29
30-49
50-64
65 or older
How long have you had your current symptoms?
*
Please Select
Less than 24 hours
1-3 days
4-7 days
More than 1 week
Please indicate which symptoms you are currently experiencing and their severity:
*
Rows
None
Mild
Moderate
Severe
Fever
1
2
3
4
Cough
5
6
7
8
Sore throat
9
10
11
12
Runny or stuffy nose
13
14
15
16
Headache
17
18
19
20
Muscle aches
21
22
23
24
Fatigue
25
26
27
28
Shortness of breath
29
30
31
32
Have you experienced any of the following in the past 14 days? (Select all that apply)
*
Close contact with someone diagnosed with an upper respiratory infection
Recent travel to areas with high infection rates
Attendance at large gatherings
None of the above
Do you have any of the following medical conditions?
*
Asthma
Chronic lung disease
Diabetes
Immunosuppression
Heart disease
None of the above
Other
Have you received a flu vaccine in the past year?
*
Yes
No
Not sure
Please rate the overall impact of your symptoms on your daily activities:
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
Is there anything else you would like to share about your symptoms or health?
Submit Assessment
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