2b. Did you (she*) use a medical facility such No as a clinic or urgent care center? Yes 2b(i). When was your (her)* last visit? 2b(ii). Why? 2b(iii). Provide any contact information (e.g., name, facility, phone number, etc.): 3. Did you/she* recently have any symptoms If any answer in question 3. is ask this “yes,” “when” such as: occurred and symptoms and reasons,” if “describe a fever? 3a. No Yes 3a(i). When? 3a(ii). Describe the fever and reasons. 3b. cough? No Yes 3b(i). When? 3b(ii). Describe the cough and reasons. 3c. diarrhea? No Yes 3c(i). When? 3c(ii). Describe diarrhea and reasons. No swollen lymph nodes or glands in the 3d. neck, armpits or groin? Yes 3d(i). When? 3d(ii). Describe swollen lymph nodes or glands and reason. 3e. weight loss?
2b. Did you (she*) use a medical facility such as a clinic or urgent care center? No Yes 2b(i). When was your (her)* last visit? 2b(ii). Why? 2b(iii). Provide any contact information (e.g., name, facility, phone number, etc.): 3. Did you/she* recently have any symptoms such as: 3a. a fever? 3b. cough? 3c. diarrhea? 3d. swollen lymph nodes or glands in the neck, armpits or groin? 3e. weight loss? No Yes No Yes No Yes No Yes If any answer in question 3. is “yes,” ask “when” this occurred and “describe symptoms and reasons,” if 3a(i). When? 3a(ii). Describe the fever and reasons. 3b(i). When? 3b(ii). Describe the cough and reasons. 3c(i). When? 3c(ii). Describe diarrhea and reasons. 3d(i). When? 3d(ii). Describe swollen lymph nodes or glands and reason.
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