Spreadsheet: 01f86a89-05d0-49db-8629-05cbd13b02a0
Sheet: Self Screening Form with Boxes

Orange County Health Care Agency Anthrax Medication Self Screening Form
Head of Household |  | Question 1 | Question 2 | Question 3 | Question 4 |  | I have had an opportunity to ask questions which were answered to my satisfaction.  I understand the benefits and risk of taking the drug as directed by my responses on this Self Screening Form and request that it be given to me for myself and those whom I have indicated on this form.  I understand that the person providing the medication may not be a medical professional.                                                  Initial: _______   Date: ______________      Refused/Referred:
Name: |  | Does the person have:                                              - Seizures?                     - Kidney Disease?                  - Liver Disease?                    - Organ Transplant?                          Is person taking:           - Cyclosporine?               - Coumadin? Warfarin?                                   - Tizanidine? | Is this person allergic to or should they not be taking:                             - Doxycycline?                                   - Tetracycline?                              - Minocycline? | Does this person have [NAME] or are they allergic to, or should not be taking:                                 - Ciprofloxacin?                                  - Levofloxacin?                         - Other "Floxacin" related drugs? | Is this person:                - Pregnant?                     - Breast feeding?             - Under 9 years old?                                 - Taking Birth Control?
Address:
City & Zip:
Phone:
Step 1 - List all household members for whom you are picking up medication, placing your name first.                                 Step 2 - For each person answer all four questions.
 |  |  |  |  |  |  | Initial: _______ |  | Date: ______________
 |  |  |  |  |  |  | Check Medication(s) Selected       (See Decision Chart Below) |  |  |  | Staff Comments
 | Last Name, First Name | Yes, No, Unsure | Yes, No, Unsure | Yes, No, Unsure | Yes, No, Unsure
1 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
2 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
3 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
4 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
5 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
6 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
7 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
8 |  |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  Yes   No   Unsure |  |  Cipro |  Doxy |  Referral
Disclaimer |  | Decision Chart |  |  |  | Medication Selection
This form has been reviewed and approved by medical professionals from the Orange County Health Care Agency to be utilized as a Self Screening form to determine the type of medication you and your household members should receive or if you need a medical referral. |  | Question 1 | Question 2 | Question 3 | Question 4 | Decision - Indicate Selection in Table Above
 |  | Yes |  |  |  | Refer to Health Care Provider
 |  | No or Unsure | Yes | Yes |  | Refer to Health Care Provider
 |  | No or Unsure | Yes | No or Unsure |  | Ciprofloxacin *refer to drug fact sheet for pregnancy/birth control issues
 |  | No or Unsure | No or Unsure | Yes |  | Doxycycline *refer to drug fact sheet for pregnancy/birth control issues
 |  | No or Unsure | No or Unsure | No or Unsure | No | Ciprofloxacin or Doxycycline *check both options above
 |  | No or Unsure | No or Unsure | No or Unsure | Yes or [NAME] | Ciprofloxacin *refer to drug fact sheet for pregnancy/birth control issues