Name of facility/school:
Child’s legal name:
When symptom began, how long it lasted, how severe, how often?
Any change in child’s behavior?
Child’s temperature: ____________ Time taken: ________ (Circle: axillary [armpit], oral, rectal, ear canal, other [specify]) ________
How much and what type of food and fluid did the child take in the past 12 hours?
Number of times of urination: ______ and bowel movements: _____
How typical/normal were urine and bowel movements in the past _______ hours?
Circle or write in other symptoms:
Cough Headache Runny nose Stomachache Trouble urinating Other pain (specify)
Diarrhea Itching Sore throat Trouble breathing Vomiting
Earache Rash Stiﬀ neck Trouble sleeping Wheezing
Any medications in the past 12 hours (name, time, dose)?
Any exposure to animals, insects, soaps, new foods, or new environments?
Exposure to other people who were sick; who and what sickness?
Child’s other problems that might aﬀect this illness (eg, asthma, allergy, anemia, diabetes, emotional trauma, seizures):
What has been done so far?