Symptomatology Questionnaires

Form Approved

OMB No.

Expiration Date:

Attachment 22

Symptomatology Questionnaires

<<CDC Symptom Inventory>>

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or an other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

CDC Symptom Inventory

These questions are about physical symptoms that you may have experienced during the past month.

Fatigue

C.1 During the past month, have you had fatigue, tiredness, or exhaustion?

• ₁ Yes

• ₂ No (Skip to C.1f)

C.1a During the past month, how often have you had fatigue, tiredness or exhaustion?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.1b During the past month, how bad was your fatigue, tiredness or exhaustion?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C

.1c Prior to this past month, for how long had you had fatigue, tiredness or exhaustion?

• ₁ Less than 6 months (Skip to C.1e)

• ₂ 6 – 12 months (Skip to C.1e)

• ₃ More than 12 months

C .1d For how many years have you had fatigue, tiredness or exhaustion?

Record Number of Years

C.1e Do you consider your fatigue, tiredness or exhaustion to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.1f Has fatigue, tiredness or exhaustion been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Sore Throat

C.2 During the past month, have you had a sore throat?

• ₁ Yes

• ₂ No (Skip to C.2f)

C.2a During the past month, how often have you had a sore throat?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.2b During the past month, how bad was your sore throat?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C

.2c Prior to this past month, for how long had you had a sore throat?

• ₁ Less than 6 months (Skip to C.2e)

• ₂ 6 – 12 months (Skip to C.2e)

• ₃ More than 12 months

C .2d For how many years have you had a sore throat?

Record Number of Years

C.2e Do you consider your sore throat to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.2f Has a sore throat been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Tender Lymph Nodes and Swollen Glands

C.3 During the past month, have you had tender lymph nodes or swollen glands in your neck or armpits?

• ₁ Yes

• ₂ No (Skip to C.3f)

C.3a During the past month, how often have you had tender lymph nodes or swollen glands?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.3b During the past month, how tender were your lymph nodes or how swollen were your glands?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.3c Prior to this past month, how long had you had tender lymph nodes or swollen glands?

• ₁ Less than 6 months (Skip to C.3e)

• ₂ 6 – 12 months (Skip to C.3e)

• ₃ More than 12 months

C .3d For how many years have you had tender lymph nodes or swollen glands?

Record Number of Years

C.3e Do you consider your tender lymph nodes or swollen glands to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.3f Have tender lymph nodes or swollen glands been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Diarrhea

C.4 During the past month, have you had diarrhea?

• ₁ Yes

• ₂ No (Skip to C.4f)

C.4a During the past month, how often have you had diarrhea?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.4b During the past month, how bad was your diarrhea?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.4c Prior to this past month, for how long had you had diarrhea?

• ₁ Less than 6 months (Skip to C.4e)

• ₂ 6 – 12 months (Skip to C.4e)

• ₃ More than 12 months

C .4d For how many years have you had diarrhea?

Record Number of Years

C.4e Do you consider your diarrhea to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.4f Has diarrhea been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Fatigue After Exertion

C.5 During the past month, have you been unusually fatigued or unwell for at least one day after exerting yourself in any way?

• ₁ Yes

• ₂ No (Skip to C.5f)

C.5a During the past month, how often have you had unusual fatigue after exertion?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.5b During the past month, how bad was your unusual fatigue after exertion?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.5c Prior to this past month, for how long had you had unusual fatigue after exertion?

• ₁ Less than 6 months (Skip to C.5e)

• ₂ 6 – 12 months (Skip to C.5e)

• ₃ More than 12 months

C .5d For how many years have you had unusual fatigue after exertion?

Record Number of Years

C.5e Do you consider your unusual fatigue after exertion to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.5f Has unusual fatigue after exertion been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Muscle Aches and Pains

C.6 During the past month, have you had muscle aches or muscle pain?

• ₁ Yes

• ₂ No (Skip to C.6f)

C.6a During the past month, how often have you had muscle aches or muscle pains?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.6b During the past month, how bad were your muscle aches or muscle pains?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.6c Prior to this past month, for how long have you had muscle aches or muscle pains?

• ₁ Less than 6 months (Skip to C.6e)

• ₂ 6 – 12 months (Skip to C.6e)

• ₃ More than 12 months

C .6d For how many years have you had muscle aches or muscle pains?

Record Number of Years

C.6e Do you consider your muscle aches or muscle pains to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.6f Have muscle aches or muscle pains been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Joint Pain

C.7 During the past month, have you had pain in several joints?

• ₁ Yes

• ₂ No (Skip to C.7f)

C.7a During the past month, how often have you had joint pain?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.7b During the past month, how bad was the joint pain?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.7c Prior to this past month, for how long had you had joint pain?

• ₁ Less than 6 months (Skip to C.7e)

• ₂ 6 – 12 months (Skip to C.7e)

• ₃ More than 12 months

C .7d For how many years have you had joint pain?

Record Number of Years

C.7e Do you consider your joint pain to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.7f Has joint pain been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Fever

C.8 During the past month, have you had a fever?

• ₁ Yes

• ₂ No (Skip to C.8f)

C.8a During the past month, how often have you had a fever?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.8b During the past month, how bad was your fever?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.8c Prior to this past month, for how long had you had a fever?

• ₁ Less than 6 months (Skip to C.8e)

• ₂ 6 – 12 months (Skip to C.8e)

• ₃ More than 12 months

C .8d For how many years have you had a fever?

Record Number of Years

C.8e Do you consider your fever to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.8f Has a fever been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Chills

C.9 During the past month, have you had chills?

• ₁ Yes

• ₂ No (Skip to C.9f)

C.9a During the past month, how often have you had chills?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.9b During the past month, how bad were your chills?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.9c Prior to this past month, for how long had you had chills?

• ₁ Less than 6 months (Skip to C.9e)

• ₂ 6 – 12 months (Skip to C.9e)

• ₃ More than 12 months

C .9d For how many years have you had chills?

Record Number of Years

C.9e Do you consider your chills to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.9f Have chills been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Unrefreshing Sleep

C.10 During the past month, has unrefreshing sleep been a problem for you?

• ₁ Yes

• ₂ No (Skip to C.10f)

C.10a During the past month, how often have you had unrefreshing sleep?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.10b During the past month, how much of a problem was unrefreshing sleep?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.10c Prior to this past month, for how long had you had unrefreshing sleep?

• ₁ Less than 6 months (Skip to C.10e)

• ₂ 6 – 12 months (Skip to C.10e)

• ₃ More than 12 months

C .10d For how many years have you had unrefreshing sleep?

Record Number of Years

C.10e Do you consider unrefreshing sleep to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.10f Has unrefreshing sleep been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Sleeping Problems

C.11 During the past month, have you had problems getting to sleep, sleeping through the night, or waking up on time?

• ₁ Yes

• ₂ No (Skip to C.11f)

C.11a During the past month, how often have you had sleeping problems?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.11b During the past month, how bad were these sleeping problems?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.11c Prior to this past month, for how long had you had sleeping problems?

• ₁ Less than 6 months (Skip to C.11e)

• ₂ 6 – 12 months (Skip to C.11e)

• ₃ More than 12 months

C .11d For how many years have you had sleeping problems?

Record Number of Years

C.11e Do you consider your sleeping problems to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.11f Have sleeping problems been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Headaches

C.12 During the past month, have you had headaches?

• ₁ Yes

• ₂ No (Skip to C.12f)

C.12a During the past month, how often have you had headaches?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.12b During the past month, how bad were your headaches?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.12c Prior to this past month, for how long had you had headaches?

• ₁ Less than 6 months (Skip to C.12e)

• ₂ 6 – 12 months (Skip to C.12e)

• ₃ More than 12 months

C .12d For how many years have you headaches?

Record Number of Years

C.12e Do you consider your headaches to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.12f Have headaches been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Memory Problems

C.13 During the past month, have you had forgetfulness or memory problems that caused you to substantially cut back on your activities?

• ₁ Yes

• ₂ No (Skip to C.13f)

C.13a During the past month, how often have you had forgetfulness or memory problems?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.13b During the past month, how bad were your forgetfulness or memory problems?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.13c Prior to this past month, for how long had you forgetfulness or memory problems?

• ₁ Less than 6 months (Skip to C.13e)

• ₂ 6 – 12 months (Skip to C.13e)

• ₃ More than 12 months

C .13d For how many years have you had forgetfulness or memory problems?

Record Number of Years

C.13e Do you consider your forgetfulness or memory problems to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.13f Have forgetfulness or memory problems been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Concentration

C.14 During the past month, have you had difficulty with thinking or concentrating that caused you to substantially cut back on your activities?

• ₁ Yes

• ₂ No (Skip to C.14f)

C.14a During the past month, how often have you had difficulty with thinking or concentrating?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.14b During the past month, how bad was your difficulty with thinking or concentrating?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.14c Prior to this past month, for how long had you had difficulty with thinking or concentrating?

• ₁ Less than 6 months (Skip to C.14e)

• ₂ 6 – 12 months (Skip to C.14e)

• ₃ More than 12 months

C .14d For how many years have you had difficulty with thinking or concentrating?

Record Number of Years

C.14e Do you consider your difficulty with thinking or concentrating to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.14f Has difficulty with thinking or concentrating been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Nausea

C.15 During the past month, have you had nausea?

• ₁ Yes

• ₂ No (Skip to C.15f)

C.15a During the past month, how often have you had nausea?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.15b During the past month, how bad was the nausea?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.15c Prior to this past month, for how long had you had nausea?

• ₁ Less than 6 months (Skip to C.15e)

• ₂ 6 – 12 months (Skip to C.15e)

• ₃ More than 12 months

C .15d For how many years have you had nausea?

Record Number of Years

C.15e Do you consider your nausea to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.15f Has nausea been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Stomach or Abdominal Pain

C.16 During the past month, have you had stomach or abdominal pain?

• ₁ Yes

• ₂ No (Skip to C.16f)

C.16a During the past month, how often have you had stomach or abdominal pain?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.16b During the past month, how bad was your stomach or abdominal pain?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.16c Prior to this past month, for how long had you had stomach or abdominal pain?

• ₁ Less than 6 months (Skip to C.16e)

• ₂ 6 – 12 months (Skip to C.16e)

• ₃ More than 12 months

C .16d For how many years have you had stomach or abdominal pain?

Record Number of Years

C.16e Do you consider your stomach or abdominal pain to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.16f Has stomach or abdominal pain been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Sinus or Nasal Problems

C.17 During the past month, have you had sinus or nasal symptoms?

• ₁ Yes

• ₂ No (Skip to C.17f)

C.17a During the past month, how often have you had sinus or nasal symptoms?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.17b During the past month, how bad were your sinus or nasal symptoms?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.17c Prior to this past month, for how long had you had sinus or nasal symptoms?

• ₁ Less than 6 months (Skip to C.17e)

• ₂ 6 – 12 months (Skip to C.17e)

• ₃ More than 12 months

C .17d For how many years have you had sinus or nasal symptoms?

Record Number of Years

C.17e Do you consider your sinus or nasal symptoms to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.17f Have sinus or nasal symptoms been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Shortness of Breath

C.18 During the past month, have you had shortness of breath?

• ₁ Yes

• ₂ No (Skip to C.18f)

C.18a During the past month, how often have you had shortness of breath?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.18b During the past month, how bad was your shortness of breath?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.18c Prior to this past month, for how long had you had shortness of breath?

• ₁ Less than 6 months (Skip to C.18e)

• ₂ 6 – 12 months (Skip to C.18e)

• ₃ More than 12 months

C .18d For how many years have you had shortness of breath?

Record Number of Years

C.18e Do you consider your shortness of breath to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.18f Has shortness of breath been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Sensitivity to Light

C.19 During the past month, have your eyes been sensitive to light?

• ₁ Yes

• ₂ No (Skip to C.19f)

C.19a During the past month, how often have you been sensitive to light?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.19b During the past month, how bad was your sensitivity to light?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.19c Prior to this past month, for how long have you been sensitive to light?

• ₁ Less than 6 months (Skip to C.19e)

• ₂ 6 – 12 months (Skip to C.19e)

• ₃ More than 12 months

C .19d For how many years have you been sensitive to light?

Record Number of Years

C.19e Do you consider your sensitivity to light to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.19f Has sensitivity to light been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Depression

C.20 During the past month, have you been depressed?

• ₁ Yes

• ₂ No (Skip to C.20f)

C.20a During the past month, how often have you been depressed?

• ₁ A little of the time

• ₂ Some of the time

• ₃ A good bit of the time

• ₄ Most of the time

• ₅ All of the time

C.20b During the past month, how bad was the depression?

• ₁ Very mild

• ₂ Mild

• ₃ Moderate

• ₄ Severe

• ₅ Very severe

C.20c Prior to this past month, for how long had you been depressed?

• ₁ Less than 6 months (Skip to C.20e)

• ₂ 6 – 12 months (Skip to C.20e)

• ₃ More than 12 months

C .20d For how many years have you had problems with depression?

Record Number of Years

C.20e Do you consider your depression to currently be part of your ill-health?

• ₁ Yes

• ₂ No

C.20f Has depression been a part of your ill-health in the past?

• ₁ Yes

• ₂ No

Other Symptoms

C.21 During the past month, have any other symptoms in addition to those we have already asked about been part of your ill-health?

• ₁ Yes

• ₂ No (Skip to C.22)

C.21a What other symptoms have been part of your ill-health during the past month?

Please specify the symptoms using the spaces below.

1.

2.

3.

4.

5.

C.22 Which of the following symptoms has bothered you the most during the past month?

Please check one box that describes that symptom that bothered you most during the past month.

• ₁

  
  

  Fatigue, tiredness, or exhaustion

• ₂ Sore throat

• ₃

  
  

  
  

  Tender lymph nodes or swollen glands in your neck or armpits

• ₄

  
  

  Diarrhea

• ₅

  
  

  Unusual fatigue for at least one day after exertion

• ₆

  
  

  Muscle aches or pains

• ₇

  
  

  Joint pain

• ₈

  
  

  Fever

• ₉

  
  

  Chills

• ₁

  
  

  0 Unrefreshing sleep

• ₁₁ Sleeping problems

• ₁

  
  

  2 Headaches

• ₁

  
  

  
  

  3 Forgetfulness or memory problems

• ₁

  
  

  4 Difficulty thinking or concentrating

• ₁

  
  

  5 Nausea

• ₁

  
  

  6 Stomach or abdominal pains

• ₁

  
  

  7 Sinus or nasal symptoms

• ₁

  
  

  8 Shortness of breath

• ₁

  
  

  9 Eye sensitivity to light

• ₂

  
  

  0 Depression

• ₂₁ Another symptom (Please specify: )