Case Control Questionnaire - GBS English

BR- ____ ____ - ____

Case-Control Study Questionnaire for the Investigation of Guillain-Barré Syndrome in Relation to Arboviral Infections

Study ID Number BR- ____ ____ - ____ □ Case □ Control

The ID number begins with the 2 digit case number (for example BR01) followed by an “A” for the case patient, a “B” for the first control, a “C” for the second control, and a”D” for the third control. For example, the second control subject matched for case number 8 would be labeled “BR-08-C.”

Interviewer: ___________________________ Date of Interview: __ __ /__ __ /______ DD MM YYYY

Neuro Symptom Onset Date for Case __ __ /__ __ /______ DD MM YYYY

The following questions are to be asked of cases AND controls during the interview:

1. Current Address: ________________________________/__________________/__________________/___________

(Street) (Town) (Province) (District)

2. Onset Address: _________________________________/__________________/__________________/___________

(for cases only if different from above; where cases spent most nights in the 2 months prior to neuro onset)

3. GPS Coordinates (Onset for cases; current for controls): __ __. __ __ __ __ __ S, __ __ __. __ __ __ __ __ E

4. Sex: □ Male □ Female

5. Race: □ White □ Hispanic □ Indigenous □ Black/African decent □ Other:_____________

6. Age when cases developed first neuro symptoms (or equivalent date for controls): ______ Years

7. What is your occupation? ________________________________________________

8. Have you been told by a clinician that you have any of the following medical conditions?

□ Diabetes □ High blood pressure □ Heart disease □ High cholesterol □ Stroke □ Kidney disease □ Liver disease □ Rheumatologic disease

□ Asthma □ COPD □ Cancer □ Surgery (within 2 months of

symptom onset)

□ Other neurologic illness:______________________________

□ Take any medication or have any condition that might impact your ability to fight infections (e.g. prednisone):

__________________________________________________

9. a. In the 2 months prior to __ __ /__ __ /2015 (neuro onset date for case), have YOU been sick at all?

□ Yes □No □ Unknown

b. If so, when did you first feel sick? __ __ /__ __ /_____

c. If so, what symptoms did you have (check all that apply)?

□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Abnormally red eyes

□ Headache □ Pain behind eyes □ Stiff neck □ Confusion

□ Abdominal pain □ Coughing □ Runny nose □ Sore throat □ Calf pain

d. If so, did you see a doctor or go to the hospital for this illness? □ Yes □ No □ Unknown

Which doctor? ________________________ Which hospital? _______________________________

e. If so, did they draw any blood for testing? □ Yes □ No □ Unknown

10. a. In the 2 months prior to __ __ /__ __ /_____ (neuro onset date for case), has anyone in your HOUSEHOLD been sick at all? □ Yes □ No □ Unknown

b. If so, when did the first household member become sick? __ __ /__ __ /_____

c. If so, what symptoms did any household members have (check all that apply)?

□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Abnormally red eyes

□ Headache □ Pain behind eyes □ Stiff neck □ Confusion

□ Abdominal pain □ Coughing □ Runny nose □ Sore throat □ Calf pain

11 a. Have you received any vaccinations in 2015? □ Yes □No □ Unknown

b. If so, which vaccine and date? _________________ __ __ /__ __ /______

□ Information verified on vaccine card □ Information provided verbally

c. If so, which vaccine and date? _________________ __ __ /__ __ /______

□ Information verified on vaccine card □ Information provided verbally

12. In 2015, what pets, farm, or other animals have lived in your house or on your property (check all that apply)?

□ Dogs □ Cats □ Mice/rats □ Pet birds □ Pet lizards /turtles

□ Goats □ Sheep □ Cows □ Chickens □ Pigs □ Other ____________

13. In 2015, how often have you gotten your drinking water from the tap?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

14. In 2015, how often have you gotten your drinking water from a well or river/stream/pond?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

15. In 2015, how often do you walk around barefoot?

□Almost always (>75%) □Often (25-75%) □Rarely (<25%) □Never (0%)

16. In 2015, have you swam or waded in a freshwater river, stream, or pond?

□Daily □Weekly □Monthly □Rarely (<once per month) □Never

17. In 2015, do you recall being bit by a mosquito? □Yes □No □Unknown

18. In 2015, have you handled any dead animals? □Yes □No □Unknown

Which? _________________­­­­­_______

19. In 2015, have you eaten or drank any of the following foods at least once per week (check all that apply)?

□ Beef □ Lamb □ Chicken □ Fish □ Shellfish

□ Milk □ Cheese □ Yogurt □ Fresh salad / uncooked greens