Answer the following questions and we will tell you if you have the symptoms of any of these four familiar ailments. IMPORTANT! This is not a medical diagnosis. For a medical diagnosis or if you have concerns consult your health care provider. Your results on the next page will merely indicate the percent that your responses are consistent with the reported symptoms of airborne allergies, the common cold, H1N1 (Swine Flu) and seasonal influenza, based upon information provided by the Centers for Disease Control & Prevention, National Institutes of Health and other sources.
1. How quickly did you develop symptoms? Gradually over a few days
Suddenly
Not sure
2. Do you have a fever? Yes
No
Not sure
3. Do you have a cough? Yes, a hacking, productive (mucus-producing) cough.
Yes, a dry and hacking, a non-productive (non-mucus producing) cough.
No
Not sure
4. Do you have general body aches? Yes, slight.
Yes, moderate.
Yes, severe.
No
Not sure
5. Do you have a stuffy nose? Yes
No
Not sure
6. Do you have chills? Yes
No
Not sure
7. Do you have diarrhea? Yes
No
Not sure
8. Do you have nausea and/or have you been vomiting? Yes
No
Not sure
9. Describe your energy level? Mildly tired
Moderately tired
Severely tired
Extremely lethargic, not making sense or generally out of it.
Normal
Not sure
10. Have you been sneezing? Yes
No
Not sure
11. Do you have a sore throat? Yes
No
Not sure
12. Have you been experiencing headaches? Yes
No
Not sure
13. Have you been experiencing chest discomfort? Yes, mild discomfort
Yes, moderate discomfort
Yes, severe discomfort. (If you are experiencing severe chest discomfort, seek medical attention immediately!)
No
Not sure
14. Do you have dark circles under your eyes? Yes
No
Not sure
15. How old are you? 5 or under
6-9
10-24
25-49
50-64
65 and older
16. Time and place. Check all that are true. It is Wintertime
It is the time year that you usually suffer from allergies
Many people in your community have H1N1 now.
Many people in your community have Seasonal Flu now.
You closely interact with somebody who currently has a cold.
17. Do you have itchy, watery eyes; itchy nose and throat? Yes
No
Not sure
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