Infant Symptoms Questionnaire

ZEN Colombia Study - Zika in Pregnant Women and Children in Colombia

Att_B6_Infant Symptoms Questionnaire 09222016

Infant Symptoms Questionnaire

OMB: 0920-1142

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STUDY ID: ___________________________


Date: __ __/__ __ __ /__ __

D D M M M Y Y


ZEN Colombia – Infant Symptoms Questionnaire


1. In the past 2 weeks, has your baby had any of the following symptoms?

Fever

0 No 1 Yes 77 Don’t know 88 Refused

Rash (not a diaper rash)

0 No 1 Yes 77 Don’t know 88 Refused

Red eyes lasting more than a couple hours

0 No 1 Yes 77 Don’t know 88 Refused



If the respondent answered YES to any of the symptoms above, continue. If not, go to Question 5.


2. If YES to fever, ask:


2a. When your baby had a fever, what was the highest temperature he/she had?


____________ degrees 1 Celsius 2 Fahrenheit 777 Don’t know 888 Refused


1 Auxillary 2 Rectal


2b. When did you first notice the fever?


__ __/__ __ __ /__ __ 777 Don’t know 888 Refused

D D M M M Y Y


2c. How many days did it last?


_________ days 666 Still ongoing 777 Don’t know 888 Refused


3. If YES to rash, ask:


3a. When your baby had a rash, did it seem itchy?


0 No 1 Yes 777 Don’t know 888 Refused


3b. Was the rash bumpy?


0 No 1 Yes 777 Don’t know 888 Refused


3c. Where was the rash? (Choose all that apply)


1 Face 2 Neck 3 Chest 4 Stomach 5 Arms 6 Hands

7 Back 8 Legs 9 Feet 777 Don’t know 888 Refused


3d. When did you first notice the rash?


__ __/__ __ __ /__ __ 777 Don’t know 888 Refused

D D M M M Y Y


3e. How many days did it last?


_________ days 666 Still ongoing 777 Don’t know 888 Refused

4. If YES to red eyes, ask:


4a. Were both eyes red or just one?

2 Both 1 Only one 777 Don’t know 888 Refused

4b. Was there any discharge? (Fluid or pus coming from the eye)

0 No 1 Yes 777 Don’t know 888 Refused


4c. When did you first notice your baby’s eyes were red?


__ __/__ __ __ /__ __ 777 Don’t know 888 Refused

D D M M M Y Y


4d. How many days did it last?


_________ days 666 Still ongoing 777 Don’t know 888 Refused


5. In the past 2 weeks, did your baby have any of the following symptoms:


Vomiting

0 No 1 Yes 77 Don’t know 88 Refused

Coughing

0 No 1 Yes 77 Don’t know 88 Refused

Sneezing

0 No 1 Yes 77 Don’t know 88 Refused

Runny nose

0 No 1 Yes 77 Don’t know 88 Refused

Swollen lymph nodes

0 No 1 Yes 77 Don’t know 88 Refused

Sleeping more than usual

0 No 1 Yes 77 Don’t know 88 Refused

Not feeding as much as usual

0 No 1 Yes 77 Don’t know 88 Refused

Skin redness without a rash

0 No 1 Yes 77 Don’t know 88 Refused

More irritable or crying more than usual

0 No 1 Yes 77 Don’t know 88 Refused

Blood in the urine

0 No 1 Yes 77 Don’t know 88 Refused

Nosebleeds

0 No 1 Yes 77 Don’t know 88 Refused


6. In the past 2 weeks, did your baby have any other unusual symptoms you would like to tell me about?



a. _________________________________________________________



b. __________________________________________________________


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