ZEN Columbia - Adult Symptoms Questionnaire - English

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

Att B5 - Adult Symptoms_052517_CLEAN

Male Partners - Adult Symptoms Questionnaire

OMB: 0920-1190

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STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-XXXX

Date: __ __/__ __ __ /__ __ __ __ Exp. Date xx/xx/20xx


D D M M M Y Y Y Y


Staff Administered: ___________________________


ADULT Symptoms Questionnaire


City: ________________________________________________


Clinic: _______________________________________________


  • Interviewer instructions: If this is the enrollment visit, say “In the past 2 weeks” instead of “Since your last study visit”.


1. Since your last study visit, have you had any of the following symptoms?


Fever

1 Yes 0 No 77 Don’t know 88 Refused

Rash

1 Yes 0 No 77 Don’t know 88 Refused

Red eyes lasting more than 2 hours

1 Yes 0 No 77 Don’t know 88 Refused

Joint pain or swelling

1 Yes 0 No 77 Don’t know 88 Refused


  • If the respondent answered YES to any of the symptoms above, go to question #2.

  • If not, go to question #7.


2. Since your last study visit, did you seek medical care for any or all of these symptoms at a health facility other than [study health facility name]?


1 Yes Go to question #2a

0 No Go to question #3

77 Don’t know Go to question #3

88 Refused Go to question #3


2a. When did you seek care?



__ __/__ __ __ /__ __ __ __ 77 Don’t know

D D M M M Y Y Y Y 88 Refused

2b. Where did you seek care?



Facility name: ____________________________


Facility location:____________________________

2c. When you sought care for these symptoms, did a medical provider tell you that you might have any of the following?


Zika virus


Dengue

1 Yes 0 No 77 Don’t know 88 Refused

Chikungunya

1 Yes 0 No 77 Don’t know 88 Refused

Mayaro

1 Yes 0 No 77 Don’t know 88 Refused

Yellow Fever

1 Yes 0 No 77 Don’t know 88 Refused

Cytomegalovirus

1 Yes 0 No 77 Don’t know 88 Refused

Rubella

1 Yes 0 No 77 Don’t know 88 Refused

Toxoplasmosis

1 Yes 0 No 77 Don’t know 88 Refused

Syphilis

1 Yes 0 No 77 Don’t know 88 Refused

Chicken Pox

1 Yes 0 No 77 Don’t know 88 Refused

Parvovirus

1 Yes 0 No 77 Don’t know 88 Refused

Herpes

1 Yes 0 No 77 Don’t know 88 Refused

Other

1 Yes: specify: ___________________________

0 No 77 Don’t know 88 Refused


3. If participant said “Yes” to fever in question #1:


3a. When you had a fever, what was the highest temperature you had?


____________ degrees Celsius

77 Don’t know 88 Refused

3b. When did the fever start?


__ __/__ __ __ /__ __ __ __ 77 Don’t know

D D M M M Y Y Y Y 88 Refused

3c. How many days did it last?


_________ days 66 Still ongoing

77 Don’t know 88 Refused


4. If participant said “Yes” to rash in question #1:


4a. When you had the rash, was it itchy?

1 Yes 0 No 77 Don’t know 88 Refused

4b. Was the rash bumpy?

1 Yes 0 No 77 Don’t know 88 Refused

4c. On what part of your body did you see the rash first?


Face

1 Yes 0 No 77 Don’t know 88 Refused

Neck

1 Yes 0 No 77 Don’t know 88 Refused

Chest

1 Yes 0 No 77 Don’t know 88 Refused

Stomach

1 Yes 0 No 77 Don’t know 88 Refused

Arms

1 Yes 0 No 77 Don’t know 88 Refused

Hands

1 Yes 0 No 77 Don’t know 88 Refused

Back

1 Yes 0 No 77 Don’t know 88 Refused

Legs

1 Yes 0 No 77 Don’t know 88 Refused

Feet

1 Yes 0 No 77 Don’t know 88 Refused

Buttocks/genital area

1 Yes 0 No 77 Don’t know 88 Refused

4d. To which parts of the body did the rash spread?


Face

1 Yes 0 No 77 Don’t know 88 Refused

Neck

1 Yes 0 No 77 Don’t know 88 Refused

Chest

1 Yes 0 No 77 Don’t know 88 Refused

Stomach

1 Yes 0 No 77 Don’t know 88 Refused

Arms

1 Yes 0 No 77 Don’t know 88 Refused

Hands

1 Yes 0 No 77 Don’t know 88 Refused

Back

1 Yes 0 No 77 Don’t know 88 Refused

Legs

1 Yes 0 No 77 Don’t know 88 Refused

Feet

1 Yes 0 No 77 Don’t know 88 Refused

Buttocks/genital area

1 Yes 0 No 77 Don’t know 88 Refused


4e. When did the rash start?


__ __/__ __ __ /__ __ __ __ 77 Don’t know

D D M M M Y Y Y Y 88 Refused

4f. How many days did it last?


_________ days 66Still ongoing

77 Don’t know 88 Refused


5. If participant said “Yes” to red eyes in question #1:


5a. When you had red eyes, were your eyes itchy?

1 Yes 0 No 77 Don’t know 88 Refused

5b. Were both of your eyes red or just one?

2 Both 1 Only one

77 Don’t know 88 Refused

5c. Was there any discharge? (Fluid or pus coming from your eye)

1 Yes 0 No 77 Don’t know 88 Refused

5d. When did you first notice your eyes were red?


__ __/__ __ __ /__ __ __ __ 77 Don’t know

D D M M M Y Y Y Y 88 Refused

5e. How many days did it last?


_________ days 66 Still ongoing

77 Don’t know 88 Refused


6. If participant said “Yes” to joint swelling or pain in question #1:


6a. When your joints were swollen or painful, which joints were affected?


Neck

1 Yes 0 No 77 Don’t know 88 Refused

Shoulders

1 Yes 0 No 77 Don’t know 88 Refused

Back

1 Yes 0 No 77 Don’t know 88 Refused

Hips

1 Yes 0 No 77 Don’t know 88 Refused

Knees

1 Yes 0 No 77 Don’t know 88 Refused

Ankles

1 Yes 0 No 77 Don’t know 88 Refused

Toes

1 Yes 0 No 77 Don’t know 88 Refused

Elbows

1 Yes 0 No 77 Don’t know 88 Refused

Wrists

1 Yes 0 No 77 Don’t know 88 Refused

Fingers

1 Yes 0 No 77 Don’t know 88 Refused

6b. When did you first notice your joints being swollen or painful?


__ __/__ __ __ /__ __ __ __ 77 Don’t know

D D M M M Y Y Y Y 88 Refused

6c. How many days did it last?


_________ days 66 Still ongoing

77 Don’t know 88 Refused



7. Since your last study visit, did you have any of the following symptoms:


Nausea

1 Yes 0 No 77 Don’t know 88 Refused

Vomiting

1 Yes 0 No 77 Don’t know 88 Refused

Diarrhea

1 Yes 0 No 77 Don’t know 88 Refused

Coughing

1 Yes 0 No 77 Don’t know 88 Refused

Sneezing

1 Yes 0 No 77 Don’t know 88 Refused

Runny nose

1 Yes 0 No 77 Don’t know 88 Refused

Sore throat

1 Yes 0 No 77 Don’t know 88 Refused

Swollen lymph nodes

1 Yes 0 No 77 Don’t know 88 Refused

Dizziness or fainting

1 Yes 0 No 77 Don’t know 88 Refused

Numbness or tingling in your hands or feet

1 Yes 0 No 77 Don’t know 88 Refused

Ringing in your ears

1 Yes 0 No 77 Don’t know 88 Refused

Tiredness or fatigue

1 Yes 0 No 77 Don’t know 88 Refused

Muscle weakness (lack of muscle strength)

1 Yes 0 No 77 Don’t know 88 Refused

Muscle aches (muscle pains)

1 Yes 0 No 77 Don’t know 88 Refused

Headache

1 Yes 0 No 77 Don’t know 88 Refused

Back pain

1 Yes 0 No 77 Don’t know 88 Refused

Abdominal pain

1 Yes 0 No 77 Don’t know 88 Refused

Eye pain (e.g., burning, sharp, dull, gritty, throbbing, or aching of the eyes)

1 Yes 0 No 77 Don’t know 88 Refused

Sensitivity to light

1 Yes 0 No 77 Don’t know 88 Refused

Pain behind the eyes (e.g., pressure behind the eyes)

1 Yes 0 No 77 Don’t know 88 Refused

Itchy skin without a rash

1 Yes 0 No 77 Don’t know 88 Refused

Skin redness without a rash

1 Yes 0 No 77 Don’t know 88 Refused

Chest pain

1 Yes 0 No 77 Don’t know 88 Refused

Shortness of breath

1 Yes 0 No 77 Don’t know 88 Refused

Blood in your urine

1 Yes 0 No 77 Don’t know 88 Refused

Nosebleeds

1 Yes 0 No 77 Don’t know 88 Refused

Black, tarry stools

1 Yes 0 No 77 Don’t know 88 Refused

Constipation

1 Yes 0 No 77 Don’t know 88 Refused

[Women only:] Vaginal bleeding

1 Yes 0 No 77 Don’t know 88 Refused

66 Not applicable

[Women only:] Vaginal discharge

1 Yes 0 No 77 Don’t know 88 Refused

66 Not applicable

[Men only:] Blood in your semen

1 Yes 0 No 77 Don’t know 88 Refused

66 Not applicable


8. Since your last study visit, have you had any other unusual symptoms you would like to tell me about?


1 Yes What symptoms? _______________________________________________

0 No

77 Don’t know

88 Refused


9. Since your last study visit, have you enrolled in another Zika Virus study?


1 Yes Which study? _______________________________________________

0 No

77 Don’t know

88 Refused


Thank you for completing this questionnaire. Please let me know if you have any questions.


Page 1 of 12

Appendix F2 – version 19/MAY/2017


CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).



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