Introduction:

You may be taking the following test for yourself or for someone else. Taking this test may help you decide if you or this other person may:

• Have H1N1 (swine) flu
• Need further treatment
• Need the swine flu shot (vaccination)

This test is not a substitute for professional medical care and advice. Work with a doctor or nurse to get the right diagnosis and treatment. This simple assessment will take 1 - 3 minutes to complete.

Please answer the following questions for yourself or the person you are caring for.

Questions:

	Select the age of the person you are taking this test for.
	Select an age range... 0-5 Months 6 months - 4 years 5 years - 18 years 19 years - 24 years 25 years - 64 years 65 years and older
	You must select an answer before continuing.

	Does the child you are taking this test for have the following serious symptoms? (check all that apply)
	Trouble breathing, such as chest pulling in with each breath, wheezing or grunting noise present, or breathing fast (greater than 60 breaths per minute in babies and infants, or greater than 40 breaths per minute in children under 3) Bluish or gray skin color Not drinking enough fluids (dry diaper for 4 to 6 hours or no urination for 8 hours in older children) Severe diarrhea or vomiting, many times during the day Not waking up or not interacting Crying that does not stop Being so irritable that the child does not want to be held A fever that went away for a day or more and now has returned, or a cough that got better and has now returned and is worse than before None of the above symptoms
	You must select an answer before continuing.

	Does the person you are taking this test for have the following serious symptoms? (check all that apply)
	Difficulty breathing, such as taking more than 20 breaths per minute, wheezing or grunting sound present, or chest pulling in with each breath Chest pain or abdominal pain that does not go away, or is getting worse Sudden and severe dizziness Severe confusion, or problems reasoning Severe vomiting, or vomiting that does not go away A fever that went away for a day or more and now has returned, or a cough that got better and has now returned and is worse than before None of the above symptoms
	You must select an answer before continuing.

	Does the person you are taking this test for have a fever of 100 °F or higher, cough, sore throat, runny nose, body aches, headache, chills, or fatigue?
	Yes No
	You must select an answer before continuing.

	What is the gender of the person you are taking this test for?
	Male Female
	You must select an answer before continuing.

	Is the person you are taking this test for pregnant?
	Yes No
	You must select an answer before continuing.

	Has the person you are taking this test for received the swine flu vaccine during this fall or winter?
	Yes No
	You must select an answer before continuing.

	Does the person you are taking this test for live with or care for children younger than 6 months of age?
	Yes No
	You must select an answer before continuing.

	Does the person you are taking this test for live in a long-term care facility for adults or children where there is currently a swine flu outbreak?
	Yes No
	You must select an answer before continuing.

	Does the person you are taking this test for work at any of the following? (check all that apply)
	Doctor's, nurse's, or therapist's office Hospital Lab or imaging office Nursing home, adult home, or other chronic care facility Day care, adult or child Public health setting Emergency responding unit None of the above
	You must select an answer before continuing.

	Is there direct contact with patients?
	Yes No
	You must select an answer before continuing.

	Does the person you are taking this test for have any of the following medical problems? (check all that apply)
	Chronic lung problems (including asthma or COPD) Heart problems (except high blood pressure) Kidney disease or failure (long-term) Liver disease (long-term) Brain or nervous system disorder Blood disorders (including sickle cell disease) Diabetes or other metabolic disorders Weak immune system (such as patients with AIDS, cancer, or any organ transplant; receiving chemotherapy or radiation therapy; or taking corticosteroid pills every day) Needing to take aspirin every day on a long-term basis None of the above
	You must select an answer before continuing.

	Does the person you are taking this test for live with, care for, or spend time with someone who has any of the following medical problems? (check all that apply)
	Chronic lung problems (including asthma or COPD) Heart problems (except high blood pressure) Kidney disease or failure (long-term) Liver disease (long-term) Brain or nervous system disorder Sickle cell disease and other blood disorders Diabetes Weak immune system (such as patients with AIDS, cancer, or any organ transplant; receiving chemotherapy or radiation therapy; or taking corticosteroid pills every day) Needing to take aspirin every day on a long-term basis Pregnant None of the above
	You must select an answer before continuing.

	Has this person you live with, care for, or spend time with received the swine flu vaccine during the current fall or winter?
	Yes No
	You must select an answer before continuing.

	Has the person you are taking this test for had close contact with someone who is known to have, or likely has, swine flu?
	Yes No or not sure
	You must select an answer before continuing.

	This is the last question. Please enter your 5 digit zipcode for statistical purposes. No personally identifiable information is being collected or stored.
	You must enter your zip code before continuing.

Review Date: 9/15/2009
Reviewed by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.