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Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)

Appendix E. Patient Diary

Directions for clinic staff: Please fill in the patient name, medical record number, and beginning date before giving this form to the patient. Please enter the day of the week on the shaded Day # 1 row (Monday, Tuesday, etc.).

Patient Name:  ______________________________________   Medical Record Number:  _____________________________

Start Date (MM/DD/YY):  ___ ___/___ ___/ ___ ___    Patient Contact Number:  _____________________________

Patient Instructions: Please fill out the information below for the next 14 days. Return this form to your provider in the attached envelope. Thanks.

Day #Day of the weekChange in Infection
(Circle One for Each Day)
Fever
(Put an X on any day you have a fever because of your skin infection.)
Clinic Visits
(Put an X on any day you return to your clinic because of your skin infection.)
Antibiotic Change for Your Skin Infection
(Please write the name of your new antibiotic on the day you start taking it.)
Urgent Care or Emergency Department
(Put an X on any day you visited the ED or Urgent Care because of your skin infection.)
Hospitalized
(Put an X on any day you were hospitalized because of your skin infection.)
WorseSameBetterAll Better     
1 1234     
2 1234     
3 1234     
4 1234     
5 1234     
6 1234     
7 1234     
8 1234     
9 1234     
10 1234     
11 1234     
12 1234     
13 1234     
14 1234     

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Page last reviewed March 2011
Internet Citation: Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA). March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaape.html