Influenza Diagnostic Evaluation Form
Please complete the following fields to assist in your influenza diagnostic evaluation. All information is essential for a thorough assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which symptoms are you experiencing?
*
Fever or chills
Cough
Sore throat
Runny or stuffy nose
Muscle or body aches
Headache
Fatigue (tiredness)
Other
Have you received an influenza vaccine this season?
*
Yes
No
Not sure
Have you had close contact with anyone diagnosed with influenza recently?
*
Yes
No
Not sure
Do you have any chronic medical conditions (e.g., asthma, diabetes, heart disease)?
*
Yes
No
Additional comments or relevant information
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