The purpose of this screening questionnaire is to screen for potentially conagious infectious diseases and to protect patients as well as staff.
INFECTIOUS DISEASES SCREENING TOOL
Assigned staff should have ALL patients answer these questions:
Have you traveled outside the U.S. in the past 21 days (3 weeks)?
Yes
No
Has a close contact (household member) traveled outside the U.S. in the past 21 days (3 weeks)?
Yes
No
Have you had close contact with a person with Ebola/Lassa/Marburg, Middle Eastern Respiratory Virus (MERS), Measles, Mumps, Chickenpox, or any other known infectious disease?
Yes
No
Do you have a fever (Temp more then 100.4 F (38 C)) or feel hot?
Yes
No
Do you have a cough, shortness of breath, or a sore throat?
Yes
No
Do you have a cough, shortness of breath, or a sore throat?
Yes
No
Do you have a rash?
Yes
No
If you answer "yes" to question 1 or 2 AND any other question, please notify staff IMMEDIATELY for further instrucitons.