ZEN Columbia - Adult Symptoms Questionnaire - English

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.

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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).