2009 Flood Public Health Screening Tool

2009 Flood Public Health Screening Tool

Shelter Location: ______

Today’s date/time: ______; ______DES ID number:______

What is your greatest need right now? ______

Do you have any medical concerns that require immediate attention? Yes No

Explain: ______

Name (Last, First):______

AKA:______

Sex: M F Race: ______

Date of Birth (mm/dd/yyyy): ______Age: ______

Emergency Contact Information: ______

Phone/pager/cellular phone number:______

Contact Name: ______City:______State:______

Who did you arrive with? (Includeother family members)

NameDOB

______

______

______

______

Does the person have: (check all that apply)

Gastrointestinal illness

Watery Diarrhea (3 or more watery bowel movements per day)

Bloody Diarrhea

Vomiting (One episode or more)

Other, specify ______

Respiratory illness

Upper respiratory tract infection(e.g. pharyngitis)

Influenza-like illness (fever and either cough or sore throat in the absence of a known cause)

Lower respiratory tract illness (e.g. pneumonia, bronchiolitis)

Tuberculosis, suspected

Pertussis, suspected

Other, specify ______

Neurologic illness

Meningitis/encephalitis, suspected (fever, mental status change, focal neurologic deficits)

History of Stroke

Other, specify ______

Dermatologic condition

Varicella, suspected (vesicular rash)

Rubella/Measles, suspected (maculopapular rash)

Scabies

Rash, acute onset + fever

Other, specify ______

Other infectious disease condition

Fever >100.4° F (38° C) ALONE without localizing signs

Jaundice (Viral hepatitis, suspected)

STDs (burning while urination, discharge, etc.)

Lice

Wound infection, specify site ______

Conjunctivitis (red eyes, ocular discharge)

Other ______

Mental Health condition

Anxiety /Depression/ Insomnia

Substance Abuse / withdrawal

Disorientation/Confusion

Acute psychosis/ Suicidal or Homicidal

Violent Behavior

Other, specify ______

Injury

Self-inflicted Injury - Intentional (violence)

Assault-related injury – Intentional (violence)

Unintentional injury (accidents)

Heat/Cold related injury

Other, specify ______

Dehydration

Pregnant -# weeks ______or # months ______

Chronic Medical Conditions

Cardiac

Hypertension

Other, specify ______

CancerType: ______

Current

History

Pulmonary

Chronic obstructive pulmonary disease (COPD)

Asthma

Other, specify ______

Kidney Disease

Dialysis dependent

Other, specify ______

Diabetes

Insulin

Oral medication

Other, specify ______

Immunocompromised condition (cancer, chemotherapy, high-dose or steroid use > 2 weeks, HIV/AIDS)

Hereditary blood disorders

Requires blood products

Other, specify ______

Known Allergies, specify ______

Medications:______

Other, specify:______

Medications (if yes, please fill out page 5)

None

Person with Disabilities

Physical disability

Mobility impairment (wheelchair, walker, etc.)

Other, specify ______

Sensory disability

Visually impaired (blindness, limited vision)

Hearing impaired

Other, specify ______

Cognitive disability

Mental retardation

Autism

Attention Deficit Hyperactivity Disorder

Other, specify ______

Resided in a group home, nursing home or assisted care facility

Other, specify ______

Home Healthcare

Are you under the care of any home healthcare? Yes No

If yes, who is your provider? ______

Since flooding in your area:

Did you drink any contaminated or dirty water (not bottled water)? Yes No

Were you exposed to any sewage, or dead bodies (human or animal)? Yes No

Were you injured, cut, or scraped? Yes No

Haveyou become ill since the flood hit? Yes No

If yes, please describe the illness or injury______

Describe any restrictions on your activities? ______

Additional documentation:______

List vaccines ______

Address, City and State where person will be placed (if known).

Address: ______City: ______State: ______

Disposition:

Referred for additional medical follow-up

Sent to shelter

Other______

Name of person completing this Form:______Date:______

Completed form (including page 5) can be faxed to the North Dakota Department of Health, Division of Disease Control at 701-328-0355.

- 1 -3-24-2009

2009 Flood Evacuee Medical Intake Form

Patient Name:______

MEDICATIONS:

Under treatment for tuberculosis at time of displacement

*If medication name unknown fill in purpose of medication (e.g., blood pressure med)

- 1 -3-24-2009