Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-A-5 – Tularemia ( Francisella tularensis )

TULAREMIA – 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 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 Sore throat Headache Feel cold all over or shiver/shake Dry cough Cough up blood Sore muscles Pain or tightness in the chest Diarrhea (loose or runny stool) Very tired Bloody diarrhea Vomiting Pain in stomach Upset stomach (nausea) Lost of appetite Swollen glands Short of breath Red, painful bumps on the skin

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