Pregnant Women Symptom Questionnaire - English

Zika Virus RNA Persistence in Pregnant Women and Congenitally Exposed Infants in Puerto Rico (ZIRP)

Att C3 - Pregnant Woman Symptom Questionnaire

Pregnant Women Symptom Questionnaire

OMB: 0920-1189

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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

Shape1

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

Shape2

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




Page 11 of 11

Version No.12.0


Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 (xxx-xxxx).


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