Annex C.

Signs and Symptoms Log Form

Confirmed Case ID: _____________________________ Date: ____________________ Region: _________________________________

Close Contact Name: _______________________________________________________
Date of Last Exposure: __________________________ Date of Voluntary Quarantine Period Ends*: __________________________________

Symptoms Date Date Date Date Date Date Date Date Date
AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM
No Symptoms
Fever (Temp.)
Cough
Sore Throat
Took Antivirals
Pneumonia
Diarrhea
Other Symptoms
1.

2.

3.

Sough Consult

Verified by:

Criscarlson C. Galendez, MAN, RN, OHN

Infection Control Department – Supervisor
Allied Care Experts (ACE) Medical Center – Pateros
License No.:0884316