Tainted Beverage_Mozambique

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____________

1. 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:

2. 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

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

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

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?

Did you find that the phome had a different flavor than usual? ( ) Yes ( ) No

If Yes, how was the flavor? (select one)

1. Metallic flavor

2. Bitter flavor

3. Bad flavor

4. Burning sensation

5. More sweet than usual

6. Other (describe)

Did you find that the phome had a different odor than usual? ( ) Yes ( ) No

If Yes, describe how it was different:

3. 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?

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

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
Chest pain
Palpitations
Respiratory symptoms
Cough
Difficulty breathing (dyspnea)
Rapid breathing
Rhonchi
Mental status symptoms
Agitation
Confusion
Headache
Vertigo
Loss of consciousness
Weakness/lack of energy
Torpor/grogginess
Convulsions/ tremor
Paresthesia
Hallucinations
Skin symptoms
Cutaneous eruption (rash)
Sweating (more than normal)
Skin irritation
Abdominal symptoms
Abdominal pain
Nausea
Vomiting
Diarrhea
Eye symptoms
Eye irritation
Tearing of the eyes
Vision problems
Yellow eyes
Red eyes
Other symptoms
Chest wall pain
Decreased urine output
Loss of hair
Fever
Other?

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)