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:______
Have youbeenvaccinatedfor: / Yes / No / Not Surea. / Td in the last 10 years?
b. / Hepatitis A (HepA)?
c. / Other Vaccines
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.
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2009 Flood Evacuee Medical Intake Form
Patient Name:______
MEDICATIONS:
Under treatment for tuberculosis at time of displacement
Name of Medication* / Dose / Frequency / Has medication?(Yes/No) / Has supply for ? days (enter number of days) / Requires medication immediately? (Yes/No) / Requires prescription refill?
(Yes/No)
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
Yes
No / Yes
No / Yes
No
*If medication name unknown fill in purpose of medication (e.g., blood pressure med)
- 1 -3-24-2009