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
File Type | application/msword |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
Last Modified By | Styczynski, Ashley Rene (CDC/OPHSS/CSELS) |
File Modified | 2016-01-12 |
File Created | 2016-01-04 |