Symptom Diary After Smallpox Vaccination Template

Symptom Diary After Smallpox Vaccination

a) Patient name: Last _________________ First______________ MI ______

b) Social Security Number: ____________-_________-_________________

c) Date of Birth: Mo_____/Day______/Yr_________

d) Age: _____years

e) Gender:

Male

Female

f) Date of smallpox vaccine administration: Mo_____/Day______/Yr_________

g) Clinic / site where vaccination was given:____________________________

h) Taken any steroids/pain/fever medications:

1-3 days before vaccine(____________)

0-30 days after vaccine(___________)

None during this period (-3 to +30 days)

i) Ethnicity

White/Caucasian

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

Hispanic

American Indian/Alaskan Native

Do not want to provide

Other (specify:___________________)

THE FIRST 4 WEEKS AFTER SMALLPOX

VACCINATION:

Week 4

Please check any symptoms present on each

indicated day recording details below

Symptoms (Y or N)

1.

Fever (record temperature. eg.101.2F)

2.

Chills (Y or N)

3.

Swelling at vaccination site (Y or N)

4.

Cough/ difficulty breathing (Y or N)

5.

Rash or vaccine-type reaction on body

6.

(Y or N, if Y describe rash and

where, below)

Bandage used (Y or N, type below)

7.

Did you seek medical care because of

8.

vaccination? (describe below)

Did you take any medications because

9.

of vaccination?(specify below)

Did you miss work/school because of

10.

vaccination?

Joint pain (0-9scale) (0=no, 9=worse)

11.

Muscle pain (0-9 scale)

12.

Headache (0-9 scale)

13.

Pain at vaccination site (0-9 scale)

14.

Swelling/tender lymph nodes (0-9

15.

scale)

Itching at vaccination site (0-9 scale)

16.

Chest pain (0-9 scale)

17.

Shortness of breath (0-9 scale)

18.

Other symptoms, illnesses, new

19.

medications, etc.(describe below)

Vaccination site appearance (using

20.

letter codes below)

If at any time you have questions about your vaccination please contact the DoD Vaccine Clinical Call Center at 1-866-210-

Date scab fell off: Mo______/Day______/Yr______

6469 (24 hrs a day, 7 days a week) or email the Vaccine Healthcare Center at https://askvhc.wramc.amedd.army.mil

Use all the letter codes that apply to describe vaccination site for each day above:

If medical care sought, where? Name of facility/MD: ________________________________________________

1= red spot

2= bump

3=reddish blister

4=whitish blister

5=scab

Permission to acquire medical records?

Yes

No

6=ulcer, crater

w=warmth

sw=swollen>3 in.

st=streaks

dr=drainage

Additional comments (use additional pages if necessary): _______________________________________________

Signature of vaccinee:

Date completed:

__________________________________________________________________

________________________________________________________________________________

_______

DATA PRIVACY NOTICE: Data requested are being collected under the authority of The Privacy Act of 1974, 5 U.S.C. §552A. The SSN is being collected because it is a unique identifier that will better

enable military staff to maintain contact with patients over time. Every effort will be made to safeguard the confidentiality of the information provided.

07 Feb 08