Assessment for Health Facilities

Approved Form

OMB No. 0920-1026

Exp. Date: 07/31/2017

EBOLA / MALARIA ASSESSMENT

OMB Approved

0920-XXXX

Expiration Date xx/xx/xxxx

CDC Assigned ID: ....................... State/territory reporting this case: ..................................... Case No: .........................

Patient name (last, first): Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____	Age: _______ yrs. mos. wks. days (circle units) Date of Birth: ____/ ____/ ________ Sex: Male Female Unknown
Physician name (last, first): Telephone Number: ( ) _________ – ___________	Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown	Race (select one or more): American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Black or African American Asian White Unknown

Symptom History	Yes	No	When did the fever start?	When did the patient first seek medical attention: Date: ____/ ____/ ________ Patient admitted to hospital: Yes No Unknown Hospital: _______________________________________ Date: ____/ ____/ ________ Hospital record No.: ________ Was the patient admitted to the ICU: Yes No Unknown Date: ____/ ____/ ________ Initial diagnosis: ____________________ (ICD-9 code) Final diagnosis: ____________________ (ICD-9 code) Is the patient insured? Yes No Unknown
Fever			____/ ____/ ________
Nausea
Vomiting
Diarrhea
Upper respiratory symptoms (cough, congestion)
Rash
Altered mental status
Jaundice

Laboratory Tests
	Yes	No	Unknown	Date and time test done mm/dd/yyyy hh:mm			Results	Date and time results available mm/dd/yyyy hh:mm
CBC				___/___/______	__ __ : __ __	am pm	N/A	___/___/______	__ __ : __ __	am pm
Chemistry panel				___/___/______	__ __ : __ __	am pm	N/A	___/___/______	__ __ : __ __	am pm
Tested for malaria?				___/___/______	__ __ : __ __	am pm
Microscopy Thin Smear				___/___/______	__ __ : __ __	am pm	positive negative	___/___/______	__ __ : __ __	am pm
Microscopy Thick Smear				___/___/______	__ __ : __ __	am pm	positive negative	___/___/______	__ __ : __ __	am pm
RDT (Binax Now)				___/___/______	__ __ : __ __	am pm	positive negative	___/___/______	__ __ : __ __	am pm
PCR				___/___/______	__ __ : __ __	am pm	positive negative	___/___/______	__ __ : __ __	am pm
Antibody testing				___/___/______	__ __ : __ __	am pm	positive negative	___/___/______	__ __ : __ __	am pm

Species (check all that apply)

Vivax Falciparum Malariae Ovale Not Determined Other species (specify) __________________

Parasitemia (%): _______________________

Public reporting burden of this collection of information is estimated to average 5 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-24); Atlanta, GA 30333; ATTN: PRA (0920-1026).

Was a travel history taken for this patient? Yes No Unknown
Is the patient a US resident? Yes No Unknown
Has the patient traveled or lived outside the U.S. since December 2013? Yes No If yes, specify:
Country:		1. ________________		2. _________________		3. ________________
Date ARRIVED IN the country (mm/dd/yyyy): Date DEPARTED the country (mm/dd/yyyy):		____/ ____/ ______ ____/ ____/ ______		____/ ____/ ______ ____/ ____/ ______		____/ ____/ ______ ____/ ____/ ______
Clinical Cerebral malaria ARDS None Was illness fatal: Yes No Unknown Complications: Renal failure Severe anemia(Hb<7) Other : ____________ If yes, date of death : _____/____/_______
Therapy for this attack (check all that apply)	Was this medication given?		Date and time medication given mm/dd/yyyy hh:mm
Artemether/lumefantrine (Coartem)	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Artesunate	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Atovaquone-Proguanil (Malarone)	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Chloroquine	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Clindamycin	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Doxycycline	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Mefloquine	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Quinidine	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Quinine	Yes Unknown No		___/___/______		__ __ : __ __		am pm
Other (specify): _____________________	Yes Unknown No		___/___/______		__ __ : __ __		am pm