Free 53700.pdf - Indiana

INDIANA INITIAL REFUGEE HEALTH ASSESSMENT
State Form 53700 (R / 11-08)

INDIANA STATE DEPARTMENT OF HEALTH Information submitted on this form is confidential pursuant to IC 16-41-8-1. Instructions are attached to the back of this form

.

Return completed form, preferably within thirty (30) days of U.S. date of arrival, to address at the bottom of this form.

Name (last, first, middle):______________________________________________ Arrival Status*: R A VT P CH 2 Date of birth (month, day, year):_______________________________________________ Gender: __________________________ Alien or Visa Registration number:________________________________________________ Volag: _______________________ U.S. Arrival date (month, day, year):__________________________________________ Country of birth: ____________________ TB Class: B1 B2 B3/Other No Class Country before USA:________________& Date of First Clinic Visit for Screening (month, day, year): _____/_____/_____ Length of time there:_______________
IMMUNIZATION RECORD: Review overseas medical exam (DS-2053), medical history (DS-3026), chest x-ray (DS-3024), and vaccination (DS-3025) if available and document immunization dates. For measles, mumps, rubella, and varicella: indicate if there is lab evidence of immunity; if so, immunizations are not needed against that particular disease. For all other immunizations: update series, or begin primary series if no immunization dates are found. (Fill in table below or attach immunization record from CHIRP.) Overseas immunizations done

VACCINE-PREVENTABLE DISEASE/ IMMUNIZATION
Measles Mumps Rubella Varicella (VZV) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT) Diphtheria-Tetanus (Td, Tdap) Polio (IPV, OPV) Hepatitis B (HBV) Haemophilus influenzae type b (Hib) Hepatitis A Influenza Pneumococcal Yes-Date(s)_____________________________ No

if there is lab evidence of immunity; immunization not needed

IMMUNIZATION DATE(S)
Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr Mo/Day/Yr

Unknown

TUBERCULOSIS SCREENING:
Tuberculin Skin Test (TST)
Date given: ________read________ ____ mm Induration (not redness)

Chest X-Ray ­ done in U.S.

(If TST or IGRA positive, Class B, or symptomatic)

Diagnosis

(must check one)

Treatment

(for TB disease or LTBI)

Past history of positive TST Given, not read Declined test Not done

IGRA Test: date____________ Type_____________________ Positive *Complete TB treatment section Negative Indeterminate TB treatment follow-up clinic if not the same as screening clinic:_____________________________________ Not done

Normal Abnormal, stable, old or healed TB Abnormal, cavitary Abnormal, non-cavitary, consistent with active TB Abnormal, not consistent with active TB Pending Declined CXR Not done

No TB infection or disease Latent TB Infection (LTBI)* Old, healed not prev. Tx TB* Old, healed prev. Tx TB Active TB disease ­ (suspected or confirmed)* Pending Incomplete eval., lost to F/U

Start Date: ___/____/____
or Reason for not treating

Completed Tx overseas Declined treatment Medically contraindicated Moved out of IN Lost to follow-up Further eval. pending Other: ______________

HEPATITIS B SCREENING:

1. Anti-HBs (check one) Negative Positive; Note if positive, patient is immune. Indeterminate Results pending 2. HBsAg (check one) Negative Positive* Indeterminate Results pending *Note: if positive HBsAg, patient is infected with HBV and infectious to contacts. It is especially important to screen all household contacts. If positive HBsAg, were all household contacts screened? Yes were all susceptibles started on vaccine? Yes No Contacts not screened why not? _____________________________________ 3. Anti-HBc (check one) Negative Positive Results pending Not done Please turn the page for more tests

Alien or Visa Registration number _____________________________________________________________________________

SEXUALLY TRANSMITTED INFECTIONS: (check one for each of the following) 1. Syphilis Negative Positive; treated: Yes No Results pending 2. Gonorrhea Negative Positive; treated: Yes No Results pending 3. Chlamydia Negative Positive; treated: Yes No Results pending 4. HIV Negative Positive; referred to specialist? Yes No 5. Other, specify: _______________________ Negative Positive; treated: Yes INTESTINAL PARASITE SCREENING:
Was screening for parasites done? (check one)

Not done, why not?___________________________ Not done, why not?___________________________ Not done, why not?___________________________ Not done, why not?___________________________ No Results pending

Not screened for parasites; why not? ______________________________________________________________________________ Screened, results pending Screened, no parasites found Screened, non-pathogenic parasites found Screened, pathogenic parasite(s) found (check all that apply):
Ascaris Clonorchis Entamoeba histolytica Giardia Hookworm If not treated, why not? Treated? Treated? Treated? Treated? Treated? Yes Yes Yes Yes Yes No No No No No Paragonimus Schistosoma Strongyloides Trichuris Other (specify): __________________________ Treated? Treated? Treated? Treated? Treated? Yes Yes Yes Yes Yes No No No No No

CBC with differential done? Yes No If yes, was Eosinophilia present? Yes No Results pending If yes, was further evaluation done? Yes No

Currently Pregnant (check one): Yes No No test done

Please fill in for all refugees:
HEMOGLOBIN HEMATOCRIT LEAD (only for <6 yrs old)

MALARIA SCREENING (check one):

% Not screened for malaria; (e.g., No symptoms and history not suspicious of malaria) Screened, results pending Height_________ Weight__________ B/P__________ Screened, no malaria species found in blood smears Screened, malaria species found (please specify): _____________________________________________________________________________ If malaria species found: Treated? Yes No; Referred for malaria treatment? Yes No If referred for malaria treatment, specify physician/clinic:_______________________________________________________________________
Dental Vision Hearing Family Planning Dermatology Public Health Nurse (PHN) OB/GYN Pediatrics Endocrinology Urology Family Practice Neurology Other Referral ____________________________________

REFERRALS (check all that apply):
Primary Care Provider Mental Health WIC GI General Medicine Ear, Nose & Throat (ENT) Hematology

INTERPRETER NEEDED:

Yes, language(s) needed: __________________________________________

No

Note: Fill out the Indiana Refugee Health Assessment Form indicating the results of the tests listed on this form and return to the local public health department noted below within thirty (30) days of receipt. For more information, contact the TB/Refugee Health Program, Indiana State Department of Health at: (317) 233-1321.

Screening Clinic __________________________________________________ Physician/PA/NP/RN (Last)_____________________(First)___________________
(please circle)

Address ____________________________________________________ City ______________________________________ State ________ Zip _____________ Telephone ( ) ___________________________ Fax ( ) _____________________________ Date screening completed _______/_______/_______

Name/title person completing form _________________________________________________________________________________________________________ MAIL OR FAX TO YOUR LOCAL HEALTH DEPARTMENT ADDRESS BELOW:

Indiana State Department of Health Initial Communicable Disease Health Screening Tests *R=Refugee
A=Asylee VT=Victim of Trafficking P=Parolee CH=Cuban or Haitian 2=Secondary

Disease or Condition Immunizations

Screening Recommendations Assess and update immunizations for each individual. For measles, mumps, rubella, and varicella: indicate if there is lab evidence of immunity; if so, immunizations are not needed against that particular disease. For all other immunizations: update series, or begin primary series if no immunization dates are found. If you need assistance translating immunization records or determining needed immunizations, go to www.cdc.gov and search "Immunization Toolbox." Always update the personal immunization record card. Perform a tuberculin skin test (TST) or IGRA Test (QuantiFERON Gold QFT-G or TSpot) for all individuals regardless of BCG history, unless documented previous positive test. Pregnancy is not a medical contraindication for TST testing or for treatment of active or latent TB. TST administered prior to 6 months of age may yield false negative results. A chest x-ray should be performed for all individuals with a positive TST or QFT test. A chest x-ray should also be performed regardless of TST results for: ·those with a TB Class A or B designation from overseas exam, and ·those who have symptoms compatible with TB disease. Administer a hepatitis B screening panel including hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) to all adults and children. Vaccinate previously unvaccinated and susceptible children, 0-18 years of age. Refer all persons with chronic HBV infection for additional ongoing medical evaluation. Vaccinate susceptible adults at increased risk for HBV infection. Evaluate for eosinophilia by obtaining a CBC with differential and conduct stool examinations for ova and parasites; two stool specimens should be obtained more than twenty-four (24) hours apart. If parasites are identified, one stool specimen should be submitted 2-3 weeks after completion of therapy to determine response to treatment. Eosinophilia requires further evaluation for pathogenic parasites, even with two negative screening stool examinations. Screen for syphilis by administering VDRL or RPR. Confirm positive VDRL or RPR by FTA-ABS/MHATP or other confirmatory test. Repeat VDRL/FTA in two (2) weeks if lesions typical of primary syphilis are noted and person is sero-negative on initial screening. Use your clinical judgment to screen for chlamydia and gonorrhea using urine testing if possible. Screen for HIV and other STDs if indicated by self-report or endemicity in homeland. Screen those refugees who present with symptoms suspicious of malaria. For asymptomatic refugees from highly endemic areas, i.e., sub-Saharan Africa, screen or presumptively treat if no documented pre-departure therapy (note contraindications for pregnant or lactating women and children < 5 kg). Venous blood lead level (BLL) screening is recommended for all refugee children under six (6) years. An elevated blood lead test is a result >=10ug /dl of blood. Depending on blood lead level, follow-up testing and appropriate management may be needed.

Tuberculosis (TB)

Hepatitis B

Intestinal Parasites

Sexually Transmitted Infections

Malaria

Lead

Other Recommended Health Issues to Consider Health Problems Hematologic disorders (eosinophilia, anemia, microcytosis), dental caries, nutritional deficiencies, thyroid disease, otorhinologic and ophthalmologic problems, history of trauma, dermatologic abnormalities. Screening CBC, serum chemistry profiles, urinalysis, height, weight, vision and hearing evaluation and blood pressure. Assess mental health needs (e.g., headaches, nightmares, depression). Refer to other health resources as needed.

Information on this form is collected for the Indiana State Department of Health (ISDH), by authority of Section 412(c)(3) of the Immigration and Nationality Act as amended by the Refugee Act of 1980. This assessment form follows the guidelines for medical screening (State Letter 95-37) developed by the Office of Refugee Resettlement (ORR), in collaboration with the Public Health Service (PHS), the Office of Refugee Health (ORH) and the Division of Quarantine, the Center for Disease Control and Prevention (CDC).

For more information contact: TB/Refugee Health Program, Indiana State Department of Health 2 North Meridian St. 6-A, Indianapolis, IN 46204 (317) 233-1321 www.in.gov/isdh