Initial Participants (Health Questionnaire) Phase 1

Factors Influencing the Transmission of Influenza

Att 4-health questionnaire_Influenza 11 15 10

Initial Participants (Health Questionnaire) Phase 1

OMB: 0920-0888

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Attachment 4:

Health Questionnaire










































Name: Record Number: FC


Age:

Gender: M F

Height:

Weight:


1. Do you have any respiratory illness such as severe asthma, COPD or tuberculosis?

YES

NO

2. Besides the flu, do you have any other illnesses such as diabetes or heart disease?

YES

NO

3. During this study, you will be asked to inhale deeply and cough hard several times. Do you have any condition or illness that would make it difficult or uncomfortable for you to do this?

YES

NO

4. If female, are you pregnant?

YES

NO


(Note: If the participant answers “yes” to any of the questions 1-4, they should not participate in the study)

5. Do you have any of the following symptoms? (Circle all that apply)

Fever/chills Headache Fatigue Cough Sore throat

Muscle aches Sinus congestion Runny nose

If YES, when did your symptoms begin?


6. Were you vaccinated against the flu in the past 6 months? YES NO

7. Are you currently a smoker (including occasional/recreational)?

If YES, how often do you smoke?



If NO, have you smoked in the past? How long ago and how often?

YES





YES

NO





NO


Oral temperature (°C)


Cough 1

Cough 2

Cough 3

Results from rapid influenza test


Sampler #




Positive A Positive B


FVC




Negative Invalid


PEF





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleHealth Questionnaire for study “Experimental and Theoretical Study of Early Detection and Isolation of Influenza”
Authorwdl7
File Modified0000-00-00
File Created2021-01-27

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