EFTA00283860.pdf

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