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Lutheran Hospital of Indiana

Reporting EBOLA Symptoms

If you have been to West Africa and are having EBOLA symptoms please submit an inquiry below.
Please fill out all fields
Associated Event   
Symptom Confirmation
  Does Patient Have Fever Greater Than 101.5?
Yes     No    
  Does Patient Have A Severe Headache?
Yes     No    
  Does Patient Have Muscle Pain? Yes     No    
  Does The Patient Suffer Fom Weakness? Yes     No    
  Does Patient Have Diarrhea? Yes     No    
  Is the Patient Vomiting? Yes     No    
  Does The Patient Have Abdominal (stomach) pain?
Yes     No    
  Patient Full Name
  Person Filling Out This Form
  Current Location of Patient
  Emergency Contact Phone Numbers
Please call 911 if person needs to be transported to hospital after filling out this form.