Vitalis Illness / Health Report - General
This information is purely for tracking purposes and to enable us warn other clients or staff about any public health issue.
Date
*
-
Month
-
Day
Year
Date
Name of Person Completing Form
*
First Name
Last Name
Role of Person Completing Form
*
Please Select
Client
Client Representatives
Vitalis Caregiver
Vitalis Admin Staff
Other
Is this Report for a Vitalis Client or Vitalis Staff?
*
Vitalis Client
Vitalis Staff
Name of Client
*
First Name
Last Name
Name of Staff
*
First Name
Last Name
Back
Next
Submit
Signs and Symptoms
(Please check and complete all application information)
What type of illness is reported?
*
Please Select
Conjunctivitis
MRSA
VRE
Flu/ Nasal
Common cold
Hospitalization
Others
If others, please mention here
General Symptoms
*
General Malaise
Headache
Chills
Fever- High temperature
Back Pain
Chest Pain
Unresponsive
Other Pain
None
Other
Eyes
*
Right eye reddened/inflamed
Left eye reddened/inflamed
Right eye conjuctiva red
Left eye conjuctiva red
Right eye discharge
Left eye discharge
Itching
None
Other
Gastrointestinal
*
Vomit
Loss of appetite
Cramps
Runny/Watery stool
Concentrated stool
Pain: Location
None
Other
Urinary
*
increased frequency/urgency
Pain on urination
Strong ammonia odor
Foul odor
Cloudy urine appearance
Hematuria urine appearnce
Concentrated urine appearance
None
Other
Upper Respiratory
*
Congestion
Cough
Sore throat
Malaise
General aches
None
Other
Lower Respiratory
*
Elevated Respiratory Rate
Labored breathing
Lung sounds congested
Short of breath
Pleauritic (Chest) Pain
Cough (General)
Productive Cough
None
Other
Skin
*
Heat
Rash
Pain
Swelling
Redness - localized
Drainage
None
Other
How was this illness acquired?
*
In General Community
At Agency Work Site
Not Sure
Other
If at work site, from whom was this illness / infection contracted?
*
Staff/Employee
Patient
Not Sure
Other
Other Comments:
Back
Next
Did you notify Agency supervisor?
*
Yes
No
Name of Supervisor informed?
Date
-
Month
-
Day
Year
Date
Did you notify your physician?
*
Yes
No
Date
-
Month
-
Day
Year
Date
Back
Next
What treatment was given?
Please provide additional details about the illness or health condition
Submit
Should be Empty: