Emergency Preparedness

Kern Medical Bioterrorism Response Guide Section 2-C-2 – Viral Hemorrhagic Fever

VIRAL HEMORRHAGIC FEVERS (VHF) – 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 Bleeding from the nose or mouth Headache Bleeding from the rectum or bladder Cough Cough up blood Sore muscles Extreme weakness Trouble walking Very tired Bloody diarrhea Vomiting blood Red eyes Red spots of the skin Yellow eyes Change in mental status Reduced urination Excessive urination Pain in the eyes Low back pain Chest pain Loss of vision Difficulty breathing Light hurts the eyes Swelling of legs, fingers, hands

1