Do You Have Flu or Flu-Like Symptoms?

Students, Staff, and Faculty are encouraged to self-identify if you have any flu-like symptoms by providing the following information. Individual information will be shared with the appropriate university personnel in order to address health needs. Otherwise, information will be shared in summary only, non-specific to individuals.
Name:


I.D. #


Campus:
Longview
Tyler
Austin
Dallas
Bedford
Houston-Galleria
Houston-Westchase

Residence Hall, Room # or Address


Date of Birth:


Male
Female

Phone #


Date Symptoms Began:


I have the following symptoms. Flu symptoms generally occur suddenly and not gradually. (Please mark all that apply):
Fever greater than 100F
Chills
Headache
Extreme Fatigue
Cough
Sore Throat
Runny or Stuffy Nose
Body Aches
Diarrhea
Vomiting

Other Symptoms:


I have seen a doctor.
Yes
No

Dr. __________________ has diagnosed me with _____________


Instructions or Medications Given:


I am taking over-the-counter medications that include:


I have been vaccinated with
Seasonal Influenza Vaccine
Intranasal Influenza Vaccine
H1N1 Influenza Vaccine

Approximate date of vaccination:


People with serious illness and those at high risk for complications from influenza should contact their medical provider or seek medical care. I have the following serious medical conditions: