Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-C-1 – Smallpox

SMALLPOX – 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 had contact with any person with a high fever and a rash? NO YES 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)?

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 "yes" to all that apply). Symptoms Yes Symptoms Yes Fever Backache Headache Feel cold all over or shiver/shake Cough Sore muscles Very tired Vomiting Pain in the stomach Rash on the face Sore mouth/bumps in the mouth Rash of the arms or legs Change in mental status Confusion Bleeding from eyes, nose, skin

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