Appx I_ Pre-Test Questionnaire (M/FF/CW)

Appendix I

Pre-test questionnaire

Unique Id:

Date:

Emergency point of contact: (name & phone number):

_______________________________________________________

CDC estimates the average public reporting burden for this collection of information as 5 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).

general health?
1. Do you feel well today O Yes O No
2. Have you had a cold or flu within the last two weeks? O Yes O No (if no, skip to Question 4)
3. How long has it been since you recovered from the cold or flu? ______ days
4. Have you eaten today? O Yes O No
5. Have you had at least 8 ounces of fluid in the past four hours? O Yes O No
6. Have you started or stopped taking any medications, including vitamins, O Yes O No supplements, herbal preparation/compounds, or naturopathic remedies (or changed doses) since your last physical exam with our doctor
7. Take a few minutes to review the activity sheet(s) for the test you will be O Yes O No performing today. Is there any reason why performing the tasks described may be unsafe for you?
8. Have you had any illness or injury that required you to see a doctor or go to a O Yes O No hospital for treatment since your last physical exam with our doctor?
9. Have you experienced any of the following conditions since your last physical exam with our doctor?
O Shortness of breath	O Fainting or dizzy spells
O Wheezing	O Any other lung or heart problems
O Pregnancy (or possibility of pregnancy)	O Unusual, severe headaches
O Pain or tightness in your chest	O Numbness or tingling in extremities
O Irregular heartbeat	O Any musculoskeletal pain or discomfort
O High or low blood pressure	O Hemorrhoids
O Seizures
alcohol During the past 24 hours, about how many alcoholic drinks did you drink? (One drink is equivalent to a 12-oz beer, 5-oz glass of wine, or a drink with one shot of liquor). ___________ drinks
ACUTE diarrheal ILLNESS
Please check any illnesses you have had over the past 24 hours
O Nausea and vomiting	O Diarrhea
O Fever
Please list any medications (including over the counter) that you are taking for this illness. _____________________________________________________________________________________
SLEEP
About what time do you think you fell asleep last night or earlier today? ______ AM / PM
About what time did you wake up today? ______ AM / PM
If you woke up in the middle of the night, how long were you awake? ______ Minutes
How would you rate your sleep quality overall last night?
O Very Good	O Fairly Good
O Fairly Bad	O Very Bad
HEALTH CONCERNS
Do you have any health-related concerns you want to discuss with our doctor prior to your participation in the study today?
O Yes O No
WORK CONDITIONS
In the LAST WEEK THAT YOU WORKED, how would you describe the air temperature in your work area? O Very cold O Cold O Slightly cool O Neutral O Slightly warm O Warm O Hot O Very hot
In the LAST WEEK THAT YOU WORKED, how would you describe the humidity at your work area? O Dry O Neutral O Humid
In the LAST WEEK THAT YOU WORKED, how would you describe the air circulation in your work area? O Cold air flow O Cool air flow O No air flow O Warm air flow O Hot air flow
In the LAST WEEK THAT YOU WORKED , how much did you sweat, in general? O I did not sweat O I sweat a little (i.e. armpits, face) O I sweat a moderate amount (armpits, face, chest, back) O I sweat a lot (clothes get completely wet)
In the LAST WEEK THAT YOU WORKED , how thirsty did you get? O Not thirsty at all O I got thirsty occasionally O I got thirsty frequently O I was thirsty all the time
In the LAST WEEK THAT YOU WORKED, how hot did you get in your work area? O Not hot at all O A little warm O Warm O Hot O Very hot
In the LAST WEEK THAT YOU WORKED, how physically fatigued were you at the end of your work day? O Not tired at all O A little tired O Tired O Extremely tired
How many days have you worked in an area that you felt was warm or hot: In the past week? _________ days In the past 2 weeks? ________ days
In the PAST WEEK, how many days have you worked? __________ days
How many days ago was your last shift or work day? ___________ day(s) ago

Subject’s Signature ________________________________________

Resting Heart Rate ________________________________________

Resting Blood Pressure (Left or Right Arm) _________________________

Medical officer’s Signature ___________________________________________________

Pre-test USG __________ Post-test USG _________

Pre-test weight _________ Post-test weight________

Post-test Heart Rate ________ Post-test Blood Pressure _______

Post-test Core Temp ________ Body fat % _________