日期： 学院： 班级： 导员（签名）：
晨、晚检情况 | 因病缺课情况 |
姓名 | 体温 （℃） | 主要症状 | 其它 症状 | 发病 日期 | 就诊 日期 | 就诊 医院 | 诊断结果 | 转归 |
皮 疹 |
咳嗽
| 胸痛 | 呼吸困难 |
腹泻
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呕吐
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黄疸
| 红眼 | 普通感冒 | 流感 | 水痘 | 痢疾 | 腹泻 | 流腮 | 猩红热 | 风疹 | 结核 | 麻疹 | 新冠肺炎 | 其他 诊断 |
住院
回家
隔离
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上午 | 下午 |
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填表说明： 1、“主要症状”一栏内，如有哪项情况发生，请在对应栏内划“√”没有的划“—”；2、“发病日期、就诊日期、就诊医院”项如实填写，如无划“—”。 3、“诊断结果”一栏内，如有哪项情况发生，请在对应栏内划“√”没有的划“—”。4、“住院、回家、隔离、”一栏，选择填写，没有的划“—”。
