ZIRP - Pregnant Woman Symptom Questionnaire

Att. C 3

Form Approved

OMB No. 0920-XXX

Exp. Date XX/XX/20XX

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

Public reporting burden of this collection of information is estimated to average 8 minutes, 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1189).