EBOLA VIRUS DISEASE Screen

Name: .

Age:..

Sex:

Date:..

Screening Questionnaire
1. In the past 3 weeks have you experienced any of the following?,
YES NO
COMMENTS
Abdominal Pain
_____ ____
_______________________________________
Breathing Difficulty
_____ ____
_______________________________________
Chills
_____ ____
_______________________________________
Cough
_____ ____
_______________________________________
Diarrhea
_____ ____
_______________________________________
Fatigue/Malaise/Weakness (new) _____ ____
_______________________________________
Fever
_____ ____
_______________________________________
Nausea
_____ ____
_______________________________________
Nasal Discharge
_____ ____
_______________________________________
Rash
_____ ____
_______________________________________
Sore Throat
_____ ____
_______________________________________
Shortness of Breath
_____ ____
_______________________________________
Other: ___________________________
_____ ____
_______________________________________
___________________________
2. In the past 3 weeks have you traveled through or had close contact with anyone who
has traveled through any of the following West African areas?
YES NO
COMMENTS
Guinea
_____ ____
_______________________________________
Liberia
_____ ____
_______________________________________
Nigeria
_____ ____
_______________________________________
Sierra Leone
_____ ____
_______________________________________
OTHER:____________________________________________________________
______________________________________________________________
3. If you have had contact with others (as above), what type?
YES NO
COMMENTS
Direct physical contact
_____ ____
_______________________________________
Co-worker
_____ ____
_______________________________________
Co-traveler
_____ ____
_______________________________________
Roomed together
_____ ____
_______________________________________
Other: _____________________________________________________________
4. Was the above contact person ill? [ yes ] /[ no ]
If YES? What were the
-- Symptoms: _____________________________________________________
_____________________________________________________
-- Diagnosis: ______________________________________________________
______________________________________________________
MEDICAL OFFICER:
SIGNATURE:
STAMP: