RAPID ASSESSMENT FORM FOR CMRC Tsunami Relief
EXAMPLE: How to fill out a form
Health facility Location:
Type of facility:
Time period: Beginning date:
Diagnosis of outpatients
.
Ending date:
< 5 years 5+ years
Total
Acute lower respiratory infection
35
Watery diarrhea (including
cholera)
33
Bloody diarrhea (dysentery)
5
Measles
1
Meningitis
2
Malaria
9
Acute jaundice sydnrome
(hepatitis)
1
Flooding injury (bone fracture)
2
Injury (other)
12
Injury (not flood related)
7
Gun shot wounds
Malnutrition
1
TB new cases (with/without lab
confirmation)
3
Diabetes
4
Cardiovascular disease
17
Typhoid fever
3
Other/unknown
56
Total consultations during time
period
©Rashid A. Chotani, MD, MPH, GDSAS-JHU, 1/8/2005
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98
191
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Health facility Location:
Time period: Beginning date:
Type of facility:
2005
Ending date:
Gender
Diagnosis of outpatients
No obvious complaint
.
200
< 5 yr
5-14 yr
15-49
yr
>=50 yr
Total
Fever
ALRI (Fever & Rapid Breathing)
Malaria (fever, chills, sweats, headaches, muscle
pains, nausea and vomiting)
Viral hepatitis1
Loose watery stools, 4+ per day (including cholera)
Blood or mucus in stool (dysentery)
Measles (fever and typical rash)
Meningitis2 (High fever, headache, and stiff neck;
other)
TB new cases3 (productive, prolonged cough
(duration of more than 3 weeks), chest pain, and
hemoptysis)
Dengue Fever4 ( High fever, severe frontal
headache, and joint and muscle pain )
Typhoid fever5 (Persistent high fevers, headache,
malaise, anorexia, splenomegaly, and relative
bradycardia)
Scabies6
Leptospirosis7 (fever, chills, myalgia, nausea,
diarrhea, cough, and conjunctival suffusion)
Wasting Malnutrition (<12.5 cm for 6 mo-5 y; <14.5
cm for 6-14 y; <18.5 for 15 yr or older)
Rice eaten once or not at all in past 24 hrs?
Cellulites (red and swollen skin both warm and
painful to the touch and is sometimes accompanied
by fever, malaise, chills, and headache – history of
flood related injury)
Broken/fractured bone since flood
Head injury since flood
Open wounds since flood
Gun shot/knifing wounds
Other/unknown – not informative
Severe depression
Any family members lost in flood?
Past History: Diabetes
Past History Cardiovascular disease
Past History Hypertension
Total consultations during time period
©Rashid A. Chotani, MD, MPH, GDSAS-JHU, 1/8/2005
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Viral hepatitis: atigue, headache, loss of appetite, nausea, abdominal or joint pain, fever, skin
outbreak. Jaundice is present in less than 20% of cases of viral A, B, C, D and E
Meningitis: High fever, headache, and stiff neck; other Sx nausea, vomiting, discomfort looking
into bright lights, confusion, and sleepiness; newborns and small infants, the classic symptoms of
fever, headache, and neck stiffness may be absent or difficult to detect, and the infant may only
appear slow or inactive, or be irritable, have vomiting, or be feeding poorly
TB: The symptoms of pulmonary TB include a productive, prolonged cough (duration of more
than 3 weeks), chest pain, and hemoptysis. Systemic symptoms of TB include fever, chills, night
sweats, easy fatigability, loss of appetite, and weight loss.
Dengue Fever: High fever, severe frontal headache, and joint and muscle pain. Many patients
have nausea, vomiting, and rash. The rash appears 3–5 days after onset of fever and can spread
from the torso to the arms, legs, and face.
Typhoid Fever: The hallmark of infection is persistent, high fevers. Other common symptoms
and signs include headache, malaise, anorexia, splenomegaly, and relative bradycardia.
Scabies: Pimple-like irritations, burrows or rash of the skin, especially the webbing between the
fingers; the skin folds on the wrist, elbow, or knee; the penis, the breast, or shoulder blades.
Intense itching, especially at night and over most of the body
Leptospirosis: The acute, generalized illness associated with infection can mimic other tropical
diseases (e.g., dengue fever, malaria, and typhus), and common symptoms include fever, chills,
myalgia, nausea, diarrhea, cough, and conjunctival suffusion. Manifestations of severe disease
can include jaundice, renal failure, hemorrhage, pneumonitis, and hemodynamic collapse.
©Rashid A. Chotani, MD, MPH, GDSAS-JHU, 1/8/2005
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