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PATIENT SYMPTOMS LINE LISTING (Respiratory Tract Infection) E- New Jersey Department of Health Infectious and Zoonotic Diseases Program 1 2 3 4 5 6 7 8 9 10 CDS-11 NOV 15 Discharge Date Admission Date Hospitalized? Culture Done? Pneumococcal Vaccine Given? CXR (Results) Flu Vaccine Given? Nausea/Vomit/Diarrhea Fatigue Myalgia Sore Throat SOB/Resp. Distress Nasal Congestion Cough (Dry/Productive) Max. Temp. Age/Sex Room/Job Wing Onset Date Resident Staff Name Rales/Wheeze/Rhonchi Please check (X) those items that apply and complete requested information. Comments (Note: Hospital Name; Dx; other significant clinical information; culture results, etc.)