Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-2 – Brucellosis

BRUCELLOSIS – SCREENING FORM

Current Date: Last Name: Street Address:

/

/

Medical Record Number:

First Name:

MI:

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

In the past 3 weeks, have you traveled to a foreign country(s)? If yes, identify city(s)/country(s)?

NO NO

YES YES

Have you been camping in past 3 weeks?

Have you had any insect bites in the past 3 weeks?

Have you had contact with sick animals within the past 3 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 3 weeks, have you had any of the following symptoms or ailments? (Check all that apply). Symptoms Yes Symptoms Yes Fever Pain or tightness in the chest Headache Feel cold all over or shiver/shake Cough Pain in the joints Sore muscles Very tired Diarrhea (loose or runny stool) Vomiting Diarrhea Upset stomach (nausea) Pain in stomach Lost of appetite Constipation Bad taste in the mouth Short of breath Stiff neck Pain in the lumbar area

2