DAILY COVID19 SYMPTOM MONITORING LOG

Adrian T. Avila
Name of Clinical Clerk: _________________________________________________________ Nov 4 - Nov 6
Date Started: ____________________________

Instructions: Mark if you have any of the symptoms below. Place encircle Yes or No. DO NOT LEAVE ANY SPACES BLANK. If you report any of the symptom/s, please call immediately Dr. Ma. Ermela
Talaver 09209224704. This form shall be submitted to XU JPRSM Training Office/Dr. Talaver at the end of the week.
DAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
Nov. 4, 2022 Nov. 5, 2022 Nov. 6 2022
Date
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
SpO2 % 99% 99% 99% 99% 99% 99%
Temperature 36.5 36.5 36.5 36.5 36.5 36.5
Felt Feverish/Fever Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Cough Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Shortness of Breath Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Chills Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Sore Throat Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Runny Nose Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Stuffy (Congested) Nose Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Loss of taste (partial or complete) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Loss of smell (partial or complete) Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Muscle aches Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Fatigue Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Headache Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Abdominal pain/discomfort Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Nausea Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Vomiting Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Diarrhea Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No
Intake of Anti-pyretic or Anti-
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
inflammatory: Specify
________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________
Number of Hand washing per day 8 7 10

Other Symptom(s)
**adapted from NMMC COVID-19 Symptom Monitoring Log