Dengue_AZ

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION

Specimen Label

INDIVIDUAL INTERVIEW FORM

Complete one form for each consenting individual in the household.

1. Case Patient ID # - Individual #: ________-______

2. Your name / Nombre: _________________________________________________________

First (given) Middle Last

3. How long have you been living in Arizona? Cuánto tiempo ha estado viviendo en el sur de Tejas? _____ years

4. Have you used mosquito repellent in the past three months? Ha usado repelente de mosquitos en los últimos tres meses? □Yes □ No

5. Have you traveled outside of the country, for example to Mexico, in the past three months? Ha viajado usted fuera del país, por ejemplo a México, en los últimos 3 meses?

□Yes □ No □ Do not recall/no me acuerdo

5a. If yes, specify when and where (start with most recent) – Si ha viajado, especifique donde y cuando (comenzando con el mas reciente):

	Travel destination / Destino del viaje (City, Country)	Dates of Travel / Fechas del viaje (e.g. Dec 2012–Jan 2013)	Duration of travel / Duración del viaje (weeks)
Country 1
Country 2
Country 3
Country 4
Country 5

6. Have you had a fever in the last three months? Ha tenido usted fiebre en los últimos tres meses? □ Yes □ No □ Don’t know

6a. First day of fever –primer dia con fiebre (MM/DD/YYYY): ______/_______/_______

6b. Did you seek medical attention (e.g. doctor, pharmacist, healer, etc.)? Buscó usted atención médica (doctor, farmaceútico, curandero, etc.)? □ Yes □ No

6b-1. If yes, what is the name of the health care facility where you sought care? (Si busco ayuda médica, cual es el nombre del lugar?)

__________________________________________________________________

6b-2. Where is the health care facility located? (Dónde está localizado este personal medico?)

City, State ____________, _______________________

□ United States □ Mexico □ Other

6b-3. If yes, what was the diagnosis? (Cuál fue el diagnostico?)

□ Flu □ Dengue □ Typhus /Tifo murino □ West Nile / Fiebre del Nilo □Other: _____________________________________ □Don’t know

6b-4. Were you hospitalized for this illness? Estuvo usted hospitalizado por esta enfermedad? □ Yes □ No

6b-4a. Duration of hospitalization/ Duración de la hospitalización:

_______ days

6b-4b. Hospital Name/ Nombre del hospital: _____________________

6c. During your illness, did you have any of the following:

	Yes	No	Unknown	Comments
Headache /Dolor de la cabeza
Body/muscle pain /Dolor del cuerpo o los musculos
Eye pain/ Dolor de los ojos
Rash /Erupcion de la piel
Lethargy /Letargo
Anorexia
Nausea/vomiting /Nausea/vomitando
Dizziness resulting in fainting/Mareos que resultan en desmayos
Severe persistent abdominal pain /Dolor abdominal severo y persistente
Persistent vomiting (≥3 times in 1 day) / Vómito persistente
Bruising / Moretones
Nose Bleeding / Sangrado nasal
Bleeding from gums /Sangrado en las encías
Blood in vomitus / Sangrado en el vómito
Blood in urine / Sangrado en la orina
Blood in stool / Sangrado en la excreta
Black, tarry stools / Excreta negra
Heavy vaginal bleeding / Sangrado vaginal excesivo

(To be completed by the laboratory.)

Dengue Duo Test Results (check all that are positive):

□ RT-PCR □ IgM □ None □ Not done

If rt-PCR-positive, DENV type identified: □ DENV-1 □ DENV-2 □ DENV-3 □ DENV-4

Date specimen tested (MM/DD/YYYY): _____ /_____ /______ Tested by: ________________________

Comments:

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)