Acute Influenza Infection: Antiviral Therapy
Appointment
Name
DOB
Age
Phone
Allergies
Primary Care Provider
Did you receive a flu shot for this season?
Yes
No
History of Current Illness Influenza Symptoms
Fever >100.4
Headache
Non-productive cough
Rhinitis
Myalgia
Malaise
Sore throat
Signature
Submit
Should be Empty: