Adult Symptoms Questionnaire

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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