Form 0920-1011 Patient Screening Questionnaire

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Patient Screening Questionnaire

Public reporting burden of this collection of information is estimated to average 10 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Patient ID ____ ____ - ____
Answers are being provided on behalf of:
□ Self
□ Child
Please answer the questions to the best of your ability. It is ok to say you don’t know.
1. Our records show that you (your child) was diagnosed with RMSF in ___________(mm/yyyy). Is this correct?
Yes
/
No
/
Don’t know
--If no, please provide us with the approximate date in which you (your child) had RMSF:
__________(mm/yyyy)
2. Our records also show that you (your child) left the hospital on __________________(MM/DD/YYY). Is this
correct?
Yes
/
No
/
Don’t know
3. After you left the hospital, where did you (your child) go?
□ Home
□ Another hospital
□ Nursing home

□ Rehabilita5on facility

□ Other
□ Don’t remember
Name of facility:

_______________________________________________________

How long were you there?

____________________

4. On a scale of 1 to 5 how would you rate your (your child’s) overall ability to function before your RMSF illness?
(Unable to function in my daily life) 1 — 2 — 3 — 4 — 5 (perfectly able to function)
5.

Do you feel like you (your child) has recovered fully from your RMSF illness?
Yes
/
No
/
Don’t know
--If yes:
how long did it take to get back to normal?

___________________

--If no:
have your (your child’s) symptoms improved over time?
Yes
/
No
/
Don’t know
what symptoms are you (your child) still experiencing?

_____________________________

______________________________________________________________________________
--If don’t know, proceed to next question.
6. On a scale of 1 to 5 how would you rate your (your child’s) overall ability to function since your (their) RMSF
illness?
(Unable to function in my daily life) 1 — 2 — 3 — 4 — 5 (perfectly able to function)

Patient ID ____ ____ - ____

7. Have you (your child) been diagnosed with neurologic illness since your (their) RMSF illness (such as a stroke,
dementia, Parkinson’s Disease, etc.)
Yes
/
No
/
Don’t know
--If yes:
what was the illness? __________________________________
when was it diagnosed? ________________________________

8. Are there any activities which you (your child) used to do before your RMSF illness that you (they) are unable to
do at this time?
Yes
/
No
/
Don’t know
--If yes:
please list which activities:
_____________________________________________________________________________________
_______________________________________________________________________
do you think this change is due to your (their) RMSF illness?
Yes

/

No

/

Don’t know