Pregnant Women Symptom Questionnaire - English

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Site code	Participant code	Pregnant Woman
I I	I I I I	I 0 I

Today’s date: _____/______/________

MM DD YYYY

ZIKV RNA Persistence (ZIRP): Pregnant Woman Symptom Questionnaire

TO BE COMPLETED BY PATIENT

Part I: Symptoms

We will now ask you some questions about symptoms you might have had or are currently experiencing.

1. In the past 2 weeks, did you have fever (>=100.4 F/38.0 C)? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

If YES :

1a.When did the fever start?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refuse

M M D D Y Y Y Y

1b. What was the highest temperature you had?

____________ degrees ₁ Celsius ₂ Fahrenheit ₇₇ Don’t know ₈₈ Refuse

1c. How did you take your temperature?

₁ Thermometer ₂ Feeling your forehead ₃ Other ₇₇ Don’t know ₈₈ Refuse

1c.a. If thermometer, how did you measure your temperature?

₁ Orally ₂ Rectally ₃ Under the arm ₄ In the ear ₇₇ Don’t know ₈₈ Refuse

1d. How many days did it last?

_________ days ₆₆ Still ongoing ₇₇ Don’t know ₈₈ Refuse

1e. Did you take any medication for it? ₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refuse

If yes,

₁₁ Aspirin

Dose _________ mg/kg

₁₂ Ibuprofen

Dose _________ mg/kg

₁₃ Acetaminophen (tylenol)

Dose _________ mg/kg

₁₄ Other

2. In the past 2 weeks, did you have a rash? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

If YES :

2a. On what date did the rash start?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refuse

M M D D Y Y Y Y

2b. How many days did it last?

_________ days ₆₆ Still ongoing ₇₇ Don’t know ₈₈ Refuse

2c. When you had the rash, was it itchy?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

2d. When you had the rash, what did it look like?

₀ Bumpy ₁ Blotchy ₂ Other ₇₇ Don’t know ₈₈ Refuse

2e. Where was the rash? (Check all that apply)

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

₇ Back ₈ Legs ₉ Feet ₁₀ All over my body ₇₇ Don’t know ₈₈ Refuse

3. In the past 2 weeks, did you have red eyes lasting more than a couple of hours?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

If YES :

3a. On what date did you first notice your eyes were red?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refuse

M M D D Y Y Y Y

3b. How many days did it last?

_________ days ₆₆ Still ongoing ₇₇ Don’t know ₈₈ Refuse

3c. When you had red eyes, were your eyes itchy?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

3d. Were both of your eyes red or just one?

₂ Both ₁ Only one ₇₇ Don’t know ₈₈ Refuse

3e. Was there any discharge? (Fluid or pus coming from your eye)

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

4. In the past 2 weeks, did you joint pain or swelling? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

If YES :

5a. On what date did you first notice your joints being swollen or painful?

__ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refuse

M M D D Y Y Y Y

5b. How many days did it last?

_________ days ₆₆₆ Still ongoing ₇₇₇ Don’t know ₈₈₈ Refuse

5c. When your joints were swollen or painful, which joints were affected? (Check all that apply)

₀ Neck ₁ Shoulders ₂ Back ₃ Hips ₄ Knees ₅ Ankles ₆ Toes

₇ Elbows ₈ Wrists ₉ Fingers ₇₇ Don’t know ₈₈ Refuse

5. In the past 2 weeks, did you have any of the following symptoms?

Black, tarry stools	1 Yes 0 No 77 Don’t know 88 Refuse
Blood in your urine	1 Yes 0 No 77 Don’t know 88 Refuse
Chest pain	1 Yes 0 No 77 Don’t know 88 Refuse
Constipation	1 Yes 0 No 77 Don’t know 88 Refuse
Coughing	1 Yes 0 No 77 Don’t know 88 Refuse
Diarrhea	1 Yes 0 No 77 Don’t know 88 Refuse
Dizziness or fainting	1 Yes 0 No 77 Don’t know 88 Refuse
Eye pain	1 Yes 0 No 77 Don’t know 88 Refuse
Headache	1 Yes 0 No 77 Don’t know 88 Refuse
Itchy skin without a rash	1 Yes 0 No 77 Don’t know 88 Refuse
Muscle aches	1 Yes 0 No 77 Don’t know 88 Refuse
Muscle weakness	1 Yes 0 No 77 Don’t know 88 Refuse
Nausea	1 Yes 0 No 77 Don’t know 88 Refuse
Nosebleeds	1 Yes 0 No 77 Don’t know 88 Refuse
Numbness or tingling in your hands or feet	1 Yes 0 No 77 Don’t know 88 Refuse
Ringing in your ears	1 Yes 0 No 77 Don’t know 88 Refuse
Runny nose	1 Yes 0 No 77 Don’t know 88 Refuse
Sensitivity to light	1 Yes 0 No 77 Don’t know 88 Refuse
Shortness of breath	1 Yes 0 No 77 Don’t know 88 Refuse
Skin redness without a rash	1 Yes 0 No 77 Don’t know 88 Refuse
Sneezing	1 Yes 0 No 77 Don’t know 88 Refuse
Sore throat	1 Yes 0 No 77 Don’t know 88 Refuse
Swollen lymph nodes	1 Yes 0 No 77 Don’t know 88 Refuse
Tiredness or fatigue	1 Yes 0 No 77 Don’t know 88 Refuse
Vomiting	1 Yes 0 No 77 Don’t know 88 Refuse
Vaginal bleeding	1 Yes 0 No 77 Don’t know 88 Refuse
Vaginal discharge	1 Yes 0 No 77 Don’t know 88 Refuse

6. In the past 2 weeks, have you had any other symptom from the ones mentioned above?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

6a.If YES, which ones?:

Symptom 1. _________________________________________________________

Symptom 2. __________________________________________________________

Symptom 3. __________________________________________________________

Symptom 4. __________________________________________________________

Symptom 5. __________________________________________________________

TO BE COMPLETED BY STUDY STAFF

PART I: Microbiology testing

7. Was a blood specimen taken? ₁ Yes ₀ No

7.1. If no, why no? ____________________________________

7.2 If yes,

7.2a. Date of specimen collection (mm/dd/yyyy): ____________

7.2b. Time of specimen collection (hh:mm): ____________

7.2c. Date specimen was sent to laboratory (mm/dd/yyyy): ____________

7.2d. Type of test:

₀ RT-PCR

_1. IgM

_2. RT-PCR & IgM

₃ Other

8. Was a urine sample taken? ₁ Yes ₀ No

8.1 If no, why? ____________________________________

8.2 If yes.

8.2a. Date of specimen collection (mm/dd/yyyy): ____________

8.2b. Time of specimen collection (hh:mm): ____________

8.2c. Date specimen was sent to laboratory (mm/dd/yyyy): ____________

8.2d. Type of test:

₀ RT-PCR

_1. IgM

_2. RT-PCR & IgM

₃ Other

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Version No.12.0

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