STUDY ID: __________ -___-______________________ Form Approved
OMB No. 0920-1190
Date: __ __/__ __ __ /__ __ __ __ Exp. Date 07/31/2019
D D M M M Y Y Y Y
Staff Administered: ___________________________
INFANT Symptoms Questionnaire
City: ______________________________________________
Clinic: _____________________________________________
Interviewer instructions: If this is the first study visit, say “Since your baby was born” instead of “Since your baby’s first study visit”.
Let’s first update your baby’s insurance information.
1. What type of health insurance does your baby have?
1 Contributory 2 Subsidized 3 Not insured 4 Specialized 5 Exception
6 Indeterminate / independent 77 Don’t know 88 Refused
2. What is the name of your baby’s health insurance provider?
Name: _________________________________________ 77 Don’t know 88 Refused
Now we have some questions about feeding your baby.
3. How are you currently feeding your baby?
Breast milk at the breast |
1 Yes 0 No 77 Don’t know 88 Refused |
Breast milk from a bottle |
1 Yes 0 No 77 Don’t know 88 Refused |
Infant formula from a bottle |
1 Yes 0 No 77 Don’t know 88 Refused |
Solid foods |
1 Yes 0 No 77 Don’t know 88 Refused |
Milk or other nutrition through a feeding tube or intravenously |
1 Yes 0 No 77 Don’t know 88 Refused |
4. Have you noticed your baby having any difficulty related to feeding?
Excessive spitting up |
1 Yes 0 No 77 Don’t know 88 Refused |
Excessive drooling |
1 Yes 0 No 77 Don’t know 88 Refused |
Gagging/retching/coughing |
1 Yes 0 No 77 Don’t know 88 Refused |
Difficulty swallowing |
1 Yes 0 No 77 Don’t know 88 Refused |
Difficulty latching to the breast |
1 Yes 0 No 77 Don’t know 88 Refused 99 Not Applicable |
Difficulty sucking at the breast or bottle |
1 Yes 0 No 77 Don’t know 88 Refused 99 Not Applicable |
Arching back/squirming away |
1 Yes 0 No 77 Don’t know 88 Refused |
Other: _______________________ |
1 Yes 0 No 77 Don’t know 88 Refused |
5. How many hours per day would you say your baby cries, on average:
0 <1 hour 1 1-3 hours 2 3-6 hours 3 6-9 hours 4 9-12 hours 5 >12 hours
77 Don’t know 88 Refused
6. Since your baby’s last study visit, did you seek medical care for your baby at a health facility other than [study health facility name]?
1 Yes Go to question #6a
0 No Go to question #7
77 Don’t know Go to question #7
88 Refused Go to question #7
6a. If YES, fill in the table below: |
||
Reason |
Date of visit |
|
Because your baby was sick (for example, a fever, rash, etc.) |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Tests |
||
Cranial ultrasound |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
MRI |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
CAT scan |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Hearing screening |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Vision screening |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Other:_____________ |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Providers |
||
Pediatrician |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Occupation/physical therapy |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Neurologist |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Gastroenterologist |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Other:______________ |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
Hospitalization |
1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused |
Date of admission: __ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused |
6b. If YES, did a medical provider tell you that your baby might have any of the following? |
||
Zika virus |
1 Yes 0 No 77 Don’t know 88 Refused |
|
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 |
7. Since your baby’s last study visit, has your baby had any of the following symptoms?
Fever |
1 Yes 0 No 77 Don’t know 88 Refused |
Rash (not a diaper 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 (difficulty in moving) |
1 Yes 0 No 77 Don’t know 88 Refused |
Vomiting |
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 |
Swollen lymph nodes |
1 Yes 0 No 77 Don’t know 88 Refused |
Sleeping more than usual |
1 Yes 0 No 77 Don’t know 88 Refused |
Not feeding as much as usual |
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 |
Blood in the urine |
1 Yes 0 No 77 Don’t know 88 Refused |
Nosebleeds |
1 Yes 0 No 77 Don’t know 88 Refused |
If the participant answered YES to fever, rash, red eyes, or joint pain go to question #8.
If not, go to question #11.
8. If participant said “Yes” to fever in question # 7:
8a. When your baby had a fever, what was the highest temperature he/she had? |
____________ degrees Celsius 77 Don’t know 88 Refused |
8b. When did you first notice the fever? |
__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused |
8c. How many days did it last? |
_________ days 66 Still ongoing 77 Don’t know 88 Refused |
9. If participant said “Yes” to rash in question # 7:
9a. When your baby had a rash, did it seem itchy? |
1 Yes 0 No 77 Don’t know 88 Refused |
9b. Was the rash bumpy?
|
1 Yes 0 No 77 Don’t know 88 Refused |
9c. Where did you first see the rash? |
|
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 |
9d. 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 |
9d. When did you first notice the rash? |
__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused |
9e. How many days did it last? |
_________ days 66 Still ongoing 77 Don’t know 88 Refused |
10. If participant said “Yes” to red eyes in question #7:
10a. Were both eyes red or just one? |
2 Both 1 Only one 77 Don’t know 88 Refused |
10b. Was there any discharge? (Fluid or pus coming from the eye) |
1 Yes 0 No 77 Don’t know 88 Refused |
10c. When did you first notice your baby’s eyes were red? |
__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused |
10d. How many days did it last? |
_________ days 66 Still ongoing 77 Don’t know 88 Refused |
11. If participant said “Yes” to joint pain in question #7:
11a. When did you first notice the joint pain? |
__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused |
11c. How many days did it last? |
_________ days 66 Still ongoing 77 Don’t know 88 Refused |
11d. Where did you notice the joint pain?
|
|
Arms |
1 Yes 0 No 77 Don’t know 88 Refused |
Legs |
1 Yes 0 No 77 Don’t know 88 Refused |
Other |
1 Yes, specify: __________________________ 0 No 77 Don’t know 88 Refused |
12. Since your baby’s last study visit, did your baby have any other unusual symptoms you would like to tell me about?
1 Yes What symptoms? _____________________________________________________
0 No
77 Don’t know
88 Refused
13. Since your last study visit, have you or your baby enrolled in another Zika Virus study?
1 Yes, I did Which study? _______________________________________________
2 Yes, my baby did Which study? _______________________________________________
3 Yes, my baby and I did 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.
Page
Appendix F4, 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).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Lisa Haddad |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |