Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-3 – Botulism

BOTULISM - 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 2 weeks, have you traveled to other USA cities? If yes, identify city(s):

In the past 2 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 2 weeks?

Have you had any insect bites in the past 2 weeks?

Have you had contact with sick animals within the past 2 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 2 weeks, have you had any of the following symptoms or ailments? (Check all that apply). Symptoms Yes Symptoms Yes Fever Droopy eyelids Blurred vision Double vision Dry mouth Sore throat Trouble swallowing Trouble breathing Constipation Vomiting Diarrhea

3