Personal Information
Name:
Classification:	Student Employee
If Student: Campus Residence:
If Employee: Department:
Cell Phone:
Email:
Underlying Medical conditions: select any or all that apply:
Asthma Diabetes Depression Heart Condition Liver and Kidney
Other:
Date Symptoms started:
Symptoms: Check all that apply:
Sudden onset of symptoms Fever (over 101 F) Taken with thermometer
Chills Cough
Sore Throat Congestion/Stuffy Nose
Severe Body Aches
Other:
Medications: Check all that apply:
Acetaminophen (tylenol) Ibuprofen (advil, motrin) Tamiflu
Other:
Did you get the influenza vaccination this year: Yes No
Have you seen a medical provider for these symptoms: Yes No
Were you tested for or diagnosed with influenza: Yes No
If Yes, Select Type: Influenze A Influenze B
If you answered yes to most of these questions, your symptoms are suggestive of influenza.
Please indicate how you will isolate yourself during your illness:
Go Home Stay on campus
If you remain on campus, you will be expected to stay in your room, not attend classes, go to dining services, library or other public areas on campus until your fever is < 100 for 24 hours without any fever-reducing medications.
Name of person completing this form:
Can we contact you? Yes No What is the best way to contact you? Email Cell Phone Home Phone
Your Email Address:
Your cell phone number:
Your home phone number:
Health and Wellness Services will contact you about assistance should you decide to stay on campus.