Bacterial Infection Discharge Symptom Log Form
Log your post-discharge symptoms and recovery status after a bacterial infection. Please complete this form to help track your recovery progress.
Date of log
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
First name or initials
*
Which symptoms are you experiencing today?
*
Fever
Chills
Fatigue
Pain or discomfort
Redness or swelling
Nausea
Other
How severe are your current symptoms?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Current temperature (°C)
Are your symptoms improving?
*
Yes
No
Not sure
Have you started any new medications or treatments?
Yes
No
Would you like someone to follow up with you?
Yes
No
Preferred contact method (if follow-up requested)
Please Select
Phone
Email
Other
Additional notes or comments
Submit Log
Should be Empty: