Form 0920-25AU FOLLOW-UP CLINICAL SURVEY

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

ATTACHMENT 4. FOLLOW-UP CLINICAL SURVEY

Today’s Date: ________/_______/_________ Interviewer Name: _____________________________

Investigation ID: __________________________ Interview number:_________________________

1) Since our last interview, did you experience any ongoing symptoms or a relapse in symptoms?

o Yes, relapse o Yes, ongoing o No (if no, skip to 2 if applicable) o Unknown/Not sure

1a) If relapse, how many reoccurrences have you had before this one? (use chart to determine and verify which reoccurrence this might be)

o 1 o 2 o 3 o 4 o 5

1b) If relapse, if you can remember, what dates did your previous symptoms go away and then come back (if possible):

Remittance: ____________________________ Relapse: _______________________________

1c) If relapse, how would you describe the severity of the symptom relapse compared to your initial illness?

o More severe o Similar severity o Less severe o Unknown/Not sure

1d) If ongoing, did the symptoms go away? o Yes o No o Unknown/Not sure

1d.1) If yes, what date? (mm/dd/yyyy):_______________________

1e) If yes, please describe any symptoms that recurred or continued:

Fever o Yes o No o Unknown Highest temp: __________°F o Recurrence, #: ______ OR o Ongoing symptom	Chills o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Headache o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Fatigue/malaise o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Muscle aches (myalgia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Joint pain (arthralgia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Back pain Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Red eyes (conjunctival injection) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Retroorbital or eye pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Light sensitivity (photophobia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Muscle weakness o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Seizures o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Stiff neck or neck pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Confusion o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Tremors/Shaking o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Numbness or tingling o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Loss of appetite o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Nausea o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Vomiting o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Diarrhea o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Abdominal pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Sore throat o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Cough o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Shortness of breath o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Chest pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Painful urination (dysuria) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Urinary incontinence o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Difficulty emptying bladder (retention) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Painful ejaculation o Yes o No o Unknown o Not applicable o Recurrence, #: ______ OR o Ongoing symptom		Scrotal and/or testicular pain (epididymitis, orchitis) o Yes o No o Unknown o Not applicable o Recurrence, #: ______ OR o Ongoing symptom
Vaginal discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom		Penile discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom
Dizziness, lightheadedness, or vertigo o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom		Paralysis o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom
Rash o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom 5		Excessive sweating o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Hemorrhage (bleeding) [List out all options below] o Yes o No o Unknown If yes, then specify: o Nose bleeds o Bleeding gums o Blood in stool o Heavy or abnormal menstruation o Tiny spots of bleeding under the skin or mucous membranes (petechiae) o Blood in urine (hematuria) o Blood in semen (hematospermia) o Recurrence, #: ______ OR o Ongoing symptom
Other, please describe: o Recurrence, #: ______ OR o Ongoing symptom

1e) If yes, did you seek healthcare when these symptoms recurred?

o Yes o No o Unknown

1e.1) If yes, where did you seek care? Please provide dates if possible.

o Emergency department o Primary care doctor o Urgent care

o Other, specify:______________________

Date(s) of care:______________________________________________________

If the participant is male and participating in the sample collection investigation:

2. In the past 7 days, how many times did you ejaculate (not including ejaculation to collect a sample for this investigation)? ____________________________________

If the patient has not experienced symptoms for 4 weeks, inform them that they have reached the endpoint of this part of the investigation and thank them for their participation. If the participant reported a relapse in symptoms, schedule a time to repeat the interview and thank them for their participation.

CDC estimates the average public reporting burden for this collection of information as 15 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).