Natural Disaster Morbidity Report Form



|Part I: |

|VISIT INFORMATION |

|Did reason for visit occur as a result of work (paid or volunteer) involving disaster response or rebuilding efforts? Yes No/NA |

|If Yes, occupation/response role Activity at time of injury/illness |

|[pic] [pic] |

|Part III: REASON FOR VISIT (Please check all categories related to patient’s current reason for seeking care) |

|TYPE OF INJURY |ACUTE ILLNESS/SYMPTOMS |EXACERBATION OF CHRONIC DISEASE |

| | | |

|Abrasion, laceration, cut |Conjunctivitis/eye irritation |Cardiovascular, specify: |

|Avulsion, amputation |Dehydration |Hypertension |

|Concussion, head injury | |Congestive heart failure |

|Fracture |Dermatologic/skin, specify: |Diabetes |

|Sprain/strain |Rash |Immunocompromised (e.g., HIV, lupus) |

| |Infection |Neurological, specify: |

|MECHANISM OF INJURY |Infestation (e.g., lice, scabies) |Seizure |

| |Fever (≥100°F or 37.8°C) |Stroke |

|Bite/sting, specify: | |Respiratory, specify: |

|Insect |Gastrointestinal, specify: |Asthma |

|Snake |Diarrhea |COPD |

|Other specify _____________ |Bloody | |

| |Watery | |

|Burn, specify: |Nausea or vomiting | |

|Chemical |Jaundice | |

|Fire, hot object or substance |Meningitis/encephalitis | |

|Sun exposure |Neurological (e.g., altered mental status, | |

| |confused/disoriented, syncope) | |

|Cold/heat exposure, specify: | | |

|Cold (e.g., hypothermia) |Obstetrics/Gynecology, specify: | |

|Heat (e.g., stress, hyperthermia) |GYN condition not associated with pregnancy or | |

| |post-partum | |

|Electric shock |In labor | |

| |Pregnancy complication (e.g., bleeding, fluid leakage) | |

|Fall, slip, trip, specify: |Routine pregnancy check-up | |

|From height | | |

|Same level |Pain, specify: | |

| |Abdominal pain or stomachache | |

|Foreign body (e.g., glass shard) |Chest pain, angina, cardiac arrest | |

| |Ear pain or earache | |

|Hit by or against an object |Headache or migraine | |

| |Muscle or joint pain (e.g., back, hip) | |

|Motor vehicle crash, specify: |Oral/dental pain | |

|Driver/occupant |Respiratory, specify: | |

|Pedestrian/bicyclist |Congestion, runny nose, sinusitis | |

| |Cough, specify: | |

|Non-fatal drowning, submersion |Dry | |

| |Productive | |

|Poisoning, specify: |With blood | |

|Carbon monoxide exposure |Pneumonia, suspected | |

|Inhalation of fumes, dust, other gas |Shortness of breath/difficulty breathing | |

|Ingestion specify _____________ |Wheezing in chest | |

| |Sore throat | |

|Use of machinery, tools, or equipment | | |

| | | |

|Violence/assault, specify: | | |

|Self-inflicted injury/suicide attempt | | |

|Sexual assault | | |

|Other assault specify __________ | | |

| | |MENTAL HEALTH |

| | | |

| | |Agitated behavior (i.e. violent behavior/threatening |

| | |violence) |

| | |Anxiety or stress |

| | |Depressed mood |

| | |Drug/alcohol intoxication or withdrawal |

| | |Previous mental health diagnosis (i.e. PTSD) |

| | |Psychotic symptoms (i.e. paranoia) |

| | |Suicidal thoughts or ideation |

| | |ROUTINE/FOLLOW-UP |

| | | |

| | |Medication refill |

| | |If yes, how many medications? ______ |

| | |Blood sugar check Vaccination |

| | |Blood pressure check Wound care |

| | |OTHER |

| | |[pic] |

| | |Part IV: DISPOSITION |

| | | Discharge to self care |

| | |Refer to other care (e.g., clinic or physician) |

| | |Admit/refer to hospital |

| | |Left before being seen |

| | |Deceased |

| Influenza-like-illness (ILI) – Fever (temperature of 100°F [37.8°C] or greater) AND a cough or a sore throat in the absence of a KNOWN cause other than influenza |

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Form v1.9

Rev. 09/29/2009

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