<p> RAPID ASSESSMENT FORM FOR CMRC Tsunami Relief EXAMPLE: How to fill out a form Health facility Location: Type of facility: . Time period: Beginning date: Ending date: </p><p>Diagnosis of outpatients < 5 years 5+ years Total Acute lower respiratory infection 35 Watery diarrhea (including 33 cholera) Bloody diarrhea (dysentery) 5</p><p>Measles 1</p><p>Meningitis 2</p><p>Malaria 9 Acute jaundice sydnrome 1 (hepatitis) Flooding injury (bone fracture) 2</p><p>Injury (other) 12</p><p>Injury (not flood related) 7</p><p>Gun shot wounds</p><p>Malnutrition 1 TB new cases (with/without lab 3 confirmation) Diabetes 4</p><p>Cardiovascular disease 17</p><p>Typhoid fever 3</p><p>Other/unknown 56 Total consultations during time 93 98 191 period</p><p>©Rashid A. Chotani, MD, MPH, GDSAS-JHU, 1/8/2005 1 Health facility Location: Type of facility: . Time period: Beginning date: 2005 Ending date: 200 </p><p>Gender < 5 yr 5-14 yr 15-49 >=50 yr Total Diagnosis of outpatients yr No obvious complaint Fever ALRI (Fever & Rapid Breathing) Malaria (fever, chills, sweats, headaches, muscle pains, nausea and vomiting) Viral hepatitis Loose watery stools, 4+ per day (including cholera) Blood or mucus in stool (dysentery) Measles (fever and typical rash) Meningitis (High fever, headache, and stiff neck; other) TB new cases (productive, prolonged cough (duration of more than 3 weeks), chest pain, and hemoptysis) Dengue Fever ( High fever, severe frontal headache, and joint and muscle pain ) Typhoid fever (Persistent high fevers, headache, malaise, anorexia, splenomegaly, and relative bradycardia) Scabies Leptospirosis (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</p><p>©Rashid A. Chotani, MD, MPH, GDSAS-JHU, 1/8/2005 2</p>