Flu Case Report Form
Please provide detailed information to report a flu case. All fields are required for accurate reporting.
Patient Initials
*
Patient Age
*
Patient Gender
*
Male
Female
Other
Date of Symptom Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptoms Observed
*
Fever
Cough
Sore throat
Runny nose
Muscle aches
Fatigue
Other
Has the patient been hospitalized?
*
Yes
No
Patient Outcome
*
Recovered
Ongoing illness
Deceased
Location of Case (City, State/Region)
*
Date Reported
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporter Name
*
First Name
Last Name
Reporter Email
*
example@example.com
Submit Case Report
Should be Empty: