di Mount
Sinai
INFECTIOUS DISEASES SCREENING TOOL
Assigned staff should have ALL patients answer these questions:
1. Have you traveled outside the U.S. in the past 21 days
(3 weeks)?
If yes, where n Yes I I No
Has a close contact (household member) traveled
outside the U.S. in the past 21 days (3 weeks)? o Yes o No
If yes, where
2. Have you had close contact with a person with Ebola? ❑ Yes o No
3. Do you have a fever (Temp more than 100.4°F (38°C))
n Yes o No
or feel hot?
4. Do you have a cough or a sore throat? ❑ Yes o No
5. Are you vomiting or having diarrhea? o Yes ❑ No
6. Do you have a rash? ❑ Yes ❑ No
* During FLU season, think FLU *
IDSF MSHS 18May15
EFTA00283860