Individual Questionnaire

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

CHIKUNGUNYA INVESTIGATION — INDIVIDUAL INTERVIEW FORM

Public reporting burden of this collection of information is estimated to average 15 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 any 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 (0920-1011)

CHIKUNGUNYA INVESTIGATION — INDIVIDUAL INTERVIEW FORM
Team #: _______ Interviewer: _________ Date of interview: _____/_____/________
Individual ID (e.g., SJ-1-A-1): ______-_____-_____-____
Specimen ID: (place sticker here)

1. Name: _________________________________________________________________
First (given)
Paternal
Maternal
2. Gender:

□ Male □Female

3. Date of Birth (MM/DD/YYYY): ____/_____/______

4. How long have you been living in Puerto Rico? _______ years
5. Have you been told by a clinician that you have any of the following medical conditions?

□ Diabetes □ High blood pressure
□ Stroke □ Kidney disease
□ Asthma □ Lung disease

□ Heart disease
□ Liver disease
□ Joint disease/arthritis

□ High cholesterol
□ Thyroid disease
□ Cancer

6. Do you take any of the following medications daily:

□ NSAID (e.g., aspirin, Iburpofen) □ Corticosteroids □ Antibiotics
7. Have you experiencing any new illnesses in the past 3 months? □Yes
□ No
(If more than one illness episode, detail each additional episode in Notes.)
7a. If yes, first day of illness (MM/DD/YYYY): ____/_______/_____________
7b. What symptoms did you have (check all that apply)?

□ Fever
□ Chills
□ Nausea/Vomiting
□ Diarrhea
□ Muscle pain
□ Joint pain
□ Skin rash
□ Red eyes
□ Headache
□ Pain behind eyes □ Abdominal pain
□ Cough
□ Runny nose
□ Sore throat
□ Calf pain
□ Arthritis
□ Minor bleeding (e.g., petechia, gum bleed, nosebleed, severe bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy menses)
7c. How long did this illness last? ______ days
7d. Did you go to the doctor because of this illness?

□ Yes

□ No

7d-1. If yes, Name of hospital/clinic:_______________________________________

CHIKUNGUNYA INVESTIGATION — INDIVIDUAL INTERVIEW FORM
7d-2. What was the diagnosis?

□ Viral syndrome □ I don’t know

□Chikungunya □ Dengue
□ Other: ________________________

7d-3. Were you hospitalized for this illness?

□ Yes □

No

7d-3a. If yes, Hospital Name: ________________________________
7d-3b. Days in the hospital: _____ days
8. Have you used mosquito repellent in the past month?
9. Have you slept under a bed in the past month?

□ Daily □ Weekly □ Never

□ Yes

□ No

10. Have you traveled outside of Puerto Rico in the past 3 months? □ Yes

□ No

10a. If yes, specify where and date of return to Puerto Rico for the most recent trip:

□ United States (excluding USVI) □ Dominican Republic □Caribbean cruise
□Other: ____________________________________________________________
Date of return to PR (MM/DD/YYYY): _______/______/_____________
NOTES: