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Zika Assessment Form

  Last name

  Mid name

  First name
*Home Phone #:
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Cell Phone #:
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ZIKA Screening Tool For Pregnant Women

CDC's Response to Zika

Asses for Possible Exposure1 to Zika Virus Infection

If Pregnant Patient Answered "Yes" to Any Question, Assess for Signs and Symptoms of Zika Virus Disease

Do you live in or do you frequently travel (Daily or Weekly) to an area with active Zika virus transmission2? Yes No

Have you traveled to an area with Zika2 during pregnancy or just before you became pregnant [8 weeks before conception or 6 weeks before you last menstrual period.]? Yes No

Have you had sex (vaginal, anal, or oral sex) without a condom or shared sex toys with a partner(s) who lives in or has traveled to an area with Zika2? Yes No

Do you currently have or have you had (in the past 12 weeks) fever, rash, joint pain, or conjunctivitis (red eyes)? Yes No

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)