Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Investigation record of cases
Suspect case: Any patient with signs and symptoms of intoxication
( ) Patient record ( ) Hospitalized ( ) Community
Date_____/_____/____ ID number____________
Demographic data
First Name _______________________________ Last Name __________________________
Sex: ( ) M ( ) F Age:____ Yrs Weight____ (Kg) Height _____ (m)
Address (Neighborhood) _____________________ Reference point: __________________
Marital status: Profession/occupation:
Educational level:
Exposure data
We would like to know everything about what you drank and ate last Friday (01/09/2015)?.
Did you eat breakfast last Friday? ( ) Yes ( ) No
If Yes what did you eat? Where did you eat?
What amount did you eat? What time did you eat breakfast?
Did you eat lunch last Friday? ( ) Yes ( ) No
If Yes what did you eat? Where did you eat?
What amount did you eat? What time did you eat lunch?
Did you eat dinner last Friday? ( ) Yes ( ) No
If Yes what did you eat? Where did you eat?
What amount did you eat? What time did you eat dinner?
Write the answer in the table below:
Type of food |
Where |
How much |
Time |
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Did you drink anything last Friday morning? ( ) Yes ( ) No
Did you drink anything last Friday afternoon? Did you drink anything at night?
If Yes, what did you drink (Phombe, water, beer, soda, milk, or other drinks)?
Where did you drink? What amount did you drink? What time did you drink?
Write the answer in the table below:
Beverage |
Where |
Amount |
Time |
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Did you attend the funeral at Dona Adelia’s family’s house last Friday (01/09/2015)? ( ) Yes ( ) No
What time did you arrive at the ceremony? ____ : _______ ?
At what time did you leave? _____: ________
Did you attend by yourself? ( ) Yes ( ) No .
If No, list the people that were there with you?
Name |
Degree of kinship |
Address |
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Did you drink phombe last Friday? ( ) Yes ( ) No
If Yes, complete the table:
Amount |
Where did you drink |
Where did you drink |
Did you share with someone? |
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Did you find that the phome had a different flavor than usual? ( ) Yes ( ) No
If Yes, how was the flavor? (select one)
Metallic flavor
Bitter flavor
Bad flavor
Burning sensation
More sweet than usual
Other (describe)
Did you find that the phome had a different odor than usual? ( ) Yes ( ) No
If Yes, describe how it was different:
Clinical history
Signs and symptoms:
Have you been sick with any other illness during the last 30 days? Yes___ Nao ___
If Yes, describe the illnesses and symptoms: ________________________________________ _________________________________________________________________________
Have you been taking any medication for this disease? ( ) Yes ( ) No
If Yes Tradicional medication ( ) Which?______________________________________
Conventional medication ( ) Which? ___________________________________
Describe the medications that you took:
Medication |
Frequency |
Took for what illness? |
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Do you have any disease or chronic health condition, for example HIV, hypertention, liver problems, asthma, TB, heart problems or others? ( ) Yes ( ) No
Do you take any medication for this disease? ( ) Yes ( ) No
If Yes Tradicional medication ( ) Which?______________________________________
Conventional medication ( ) Which? ___________________________________
With what frequency do you take the medication?
Medication |
Frequency |
Disease treated |
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Did you have one or more of the following symptoms beginning last Friday (01/09/2015)?
What time did your first symptoms start? (Interviewrs should stress if a person really had this symptom)?
Symptoms |
Yes/No |
Date symptom started |
Time symptoms started |
Heart symptoms |
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Chest pain |
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Palpitations |
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Respiratory symptoms |
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Cough |
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Difficulty breathing (dyspnea) |
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Rapid breathing |
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Rhonchi |
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Mental status symptoms |
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Agitation |
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Confusion |
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Headache |
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Vertigo |
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Loss of consciousness |
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Weakness/lack of energy |
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Torpor/grogginess |
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Convulsions/ tremor |
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Paresthesia |
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Hallucinations |
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Skin symptoms |
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Cutaneous eruption (rash) |
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Sweating (more than normal) |
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Skin irritation |
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Abdominal symptoms |
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Abdominal pain |
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Nausea |
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Vomiting |
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Diarrhea |
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Eye symptoms |
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Eye irritation |
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Tearing of the eyes |
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Vision problems |
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Yellow eyes |
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Red eyes |
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Other symptoms |
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Chest wall pain |
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Decreased urine output |
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Loss of hair |
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Fever |
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Other?
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Are you receiving treatment for these symptoms? ( ) Yes ( ) No
If Yes, what type of treatment?
Patient hospitalized? ( )Yes ( ) No
If hospitalized when admitted? ______ /_______ /______ Received treatment? ( ) Yes ( ) No
Describe the type of treatment: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Laboratory findings:
Final disposition: Date of discharge ____/____/_____
Discharged home ( )
Transferred ( )
Left without being discharged ( )
Died ( )
Name of investigator:____________________________Category: ____________________
Interview date: _____/________/15
Public reporting burden of this collection of information is estimated to average 20 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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Mestrado14 |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |