Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-1 – Anthrax ( Bacillus anthracis )

ANTHRAX – SCREENING FORM Current Date: / /

Medical Record Number:

Last Name:

First Name:

MI:

Street Address:

City:

State:

Zip Code:

Home Phone Number: (

) Occupation:

Work Address:

City:

State:

Zip Code:

Age:

Date of Birth:

/

/ Sex: Date Symptoms Started:

/

/ In the

past 6 weeks, have you traveled to other USA cities? If yes, identify city(s):

In the past 6 weeks, have you traveled to a foreign country(s)? If yes, identify city(s)/country(s)?

Have you been camping in past 6 weeks?

NO NO

YES YES

Have you had any insect bites in the past 6 weeks?

Have you had contact with sick animals within the past 6 weeks? NO YES Are you currently taking any medicine(s)? (Identify all prescription/over-the-counter medicines)

Are you allergic to any medicine(s)? NO YES If yes, what medicine(s) are you allergic to?

Over the past 6 weeks, have you had any of the following symptoms or ailments? (Check all that apply). Symptoms Yes Symptoms Yes Fever Trouble breathing Upset stomach (nausea) Sweating excessively Headache Pain or tightness in the chest Dry cough Very tired Sore muscles Pain in the stomach Bloody diarrhea Vomiting blood Pain in stomach Black scab on skin Itchy skin Sore throat Trouble swallowing Pain in the neck

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