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 ❑ Yes ❑ Yes ❑ a o No Has a close contact (household member) traveled outside the U.S. in the past 21 days (3 weeks)? If yes, where 2. Have you had close contact with a person with Ebola? o Yes No 3. Do you have a fever (Temp more than 100.4°F (38°C)) or feel hot? o Yes a No 4. Do you have a cough or a sore throat? ❑ Yes No 5. Are you vomiting or having diarrhea? ❑ Yes ❑ No 6. Do you have a rash? ❑ Yes No During FLU season, think FLU * IDSF MSHS 18May15 EFTA00313614