Wisconsin Initial Refugee Health Assessment Page 4
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6F-42017 (Rev. 09/13)
Page 4 of 6
Hepatitis B Screening
Anti-HBs (check only one)
Negative
Positive; Note: if positive patient is immune
Results pending
HbsAg (check only one)
Negative
Positive
Results pending
Note: If positive, patient is infected with HBV and infectious to contacts, and it is important to screen all household contacts.
If positive HbsAg, were all household contacts screened?
Yes
No
If Yes, were all susceptibles started on vaccine?
Yes
No
If No, why not?
Referred for follow-up?
Yes
No
Anti-HBc (check only one)
Negative
Positive
Results pending
Not done
IgM anti-HBc (check only one)
Negative
Positive
Results pending
Not done
Note: If positive, patient has acute HBV infection. If positive IgM anti-HBC was patient referred for follow-up?
Yes
No
Urinanalysis (Screen for indicators of chronic conditions for any patient old enough to produce a clean catch specimen)
Glycosuria:
Positive
Negative
Proteinuria:
Positive
Negative
Hematuria:
Positive
Negative
Pregnancy Test (Urine pregnancy test for all women of childbearing age)
Screened?
Yes
(date)
Not Done
Results:
Negative
Positive
HIV Screening CDC recommends for all persons 13-64 years of age; children <13 years of age should be screened unless the
mother’s HIV status can be confirmed as negative and the child is otherwise thought to be at low risk of infection (no history of high-risk
exposures such as blood product transfusions, early sexual activity, or sexual abuse).
Negative
Positive; referred to Infectious Disease Specialist?
Yes
No
Testing not done, why?
Syphilis Screening Routine testing for syphilis for refugees >15 years of age.
Screening tests (VDRL/RPR)
Negative
Positive
Not done, why?
Positive; if treated Tx:
Not treated, why?
Confirmation test (FTA/TPPA)
Negative
Positive
Not done, why?
Chlamydia/ Gonorrhea Screening (Urine Specimen) Chlamydia testing for women ≤25 years of age or older with risk factors.
Chlamydia
Negative
Positive; treated?
Yes
No
Results pending
Not done, why?
Gonorrhea
Negative
Positive; treated?
Yes
No
Results pending
Not done, why?
Other Sexually Transmitted Diseases
Specify:
Negative
Positive; treated?
Yes
No
Results pending
Not done, why?
Intestinal Parasite Screening
Pre-departure presumptive treatment?
Yes
No
Unknown If known, specify treatment:
Was screening for parasites done?
Screened, results pending
Screened, no parasites found
Screened, parasites found: (check all that apply below)
Note: Stool tests for Strongyloides can be difficult to validate. Presumptive treatment with ivermectin is appropriate if signs and
symptoms warrant.
Ascaris
Treated?
Yes
No
Hookworm
Treated?
Yes
No
Blastocystis (non-pathogenic)
Treated?
Yes
No
Schistosoma
Treated?
Yes
No
Clonorchis
Treated?
Yes
No
Strongyloides
Treated?
Yes
No
Cryptosporidium
Treated?
Yes
No
Trichinella
Treated?
Yes
No
Cyclospora
Treated?
Yes
No
Trichuris
Treated?
Yes
No
Entomaeba histolytica
Treated?
Yes
No
Other, specify:
Treated?
Yes
No
Giardia
Treated?
Yes
No
Treated?
Yes
No
Not screened for parasites; why?
Parasites not treated; why?
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