Wisconsin Initial Refugee Health Assessment Page 5
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6F-42017 (Rev. 09/13)
Page 5 of 6
Malaria Screening
If malaria species found:
Pre-Departure presumptive treatment?
Yes
No
Unknown
All sub-Saharan Africans are presumptively treated before departure.
ovale
falciparum
vivax
malariae
Not identified
guidelines.html
Treated?
Yes
No
Referred for treatment?
Yes
No
History of malaria exposure:
Yes
No
If referred for treatment, specify physician/ clinic:
Evidence of infection or symptoms of malaria:
Yes
No
Screened:
Yes
No
Screened, results pending
Lead Screening (<17 years old)
NOTE: Recheck all children aged 6 months- 6 years within 3-6 months
Screened?
Not done
Yes
(elevated BLL ≥10µg/dL)
of arrival, regardless of results of initial lead screen.
Negative
BLL
Referred for treatment?
Yes
No
Mental Status
Does the overseas medical record indicate a diagnosis of mental illness?:
Yes
No
If yes, treated or referral
Yes
No
Are there physical signs of maltreatment (scar, deformities – torture)?
Yes
No
Did the refugee become unusually anxious or agitated during the physical exam?
Yes
No
Questions that can be asked at different points in the screen:
1. Trouble sleeping?
Yes
No
Have you experienced any nightmares?
Yes
No
2. Any change in your energy level?
Yes
No
3. Unexplained somatic symptoms (headaches, stomach aches, or back pain)?
Yes
No
4. Have you noticed any change in your appetite (increase or decrease? with weight change?)
Yes
No
If behavior or answers to probes above indicate, ask,
Are you willing or interested in speaking with a mental professional?
Yes
No
Do you have thoughts of harming yourself or hurting others?
Yes
No
5. If mental health screen is positive, identify main caregiver, inquire about caregiver stress.
How is caregiver managing stress of this role?
Blood Work
(Please Complete This Section For All Refugees; Please Attach Or Fax All Results)
CBC with differential done?
Yes
No
Hemoglobin results:
Not done Hematocrit results:
Not done
Was Eosinophilia present?
Yes
No If yes, was further evaluation done?
Yes
No
Results pending
Vitamin B12 (pg/ml)
Results:
Not done
Blood Glucose (mg/dl)
Results:
Not done
ALT:
AST:
Other:
Additional Labs and Screening (Based on risk factors and/or signs and symptoms identified during the exam)
Population specific
CMP; lipid panel
Cancer screening
Metabolic screening in newborns
Vitamin D deficiency
Sickle Cell Anemia
Hepatitis A
Hepatitis C (all sub-Saharan arrivals;
others as needed)
Referrals
(Check all that apply)
Primary Care Provider
Vision
Dermatology
Communicable Disease, ID
Mental Health referral for:
referral for:
Dental
Hearing
Public Health/WIC
Family Planning
Medical/Other:
Vitamins recommended?
Multivitamin
Prenatal
Vitamin D
Other:
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