Adult Symptoms Questionnaire

STUDY ID: ___________________________

Date: __ __/__ __ __ /__ __

D D M M M Y Y

ZEN Colombia – Adult Symptoms Questionnaire

1. In the past 2 weeks, have you had any of the following symptoms?

Fever	0 No 1 Yes 77 Don’t know 88 Refused
Rash	0 No 1 Yes 77 Don’t know 88 Refused
Red eyes lasting more than a couple hours	0 No 1 Yes 77 Don’t know 88 Refused
Joint pain or swelling	0 No 1 Yes 77 Don’t know 88 Refused

If the respondent answered YES to any of the symptoms above, continue. If not, go to Question 6.

2. If YES to fever, ask:

2a. When you had a fever, what was the highest temperature you had?

____________ degrees ₁ Celsius ₂ Fahrenheit

₇₇₇ Don’t know ₈₈₈ Refused

2b. When did the fever start?

__ __/__ __ __ /__ __ ₇₇₇ Don’t know ₈₈₈ Refused

D D M M M Y Y

2c. How many days did it last?

_________ days ₆₆₆ Still ongoing ₇₇₇ Don’t know ₈₈₈ Refused

3. If YES to rash, ask:

3a. When you had the rash, was it itchy?

₀ No ₁ Yes ₇₇₇ Don’t know ₈₈₈ Refused

3b. Was the rash bumpy?

₀ No ₁ Yes ₇₇₇ Don’t know ₈₈₈ Refused

3c. Where was the rash? (Check all that apply)

₁ Face ₂ Neck ₃ Chest ₄ Stomach ₅ Arms ₆ Hands

₇ Back ₈ Legs ₉ Feet ₇₇₇ Don’t know ₈₈₈ Refused

3d. When did the rash start?

__ __/__ __ __ /__ __ ₇₇₇ Don’t know ₈₈₈ Refused

D D M M M Y Y

3e. How many days did it last?

_________ days ₆₆₆ Still ongoing ₇₇₇ Don’t know ₈₈₈ Refused

4. If YES to red eyes, ask:

4a. When you had red eyes, were your eyes itchy?

₀ No ₁ Yes ₇₇₇ Don’t know ₈₈₈ Refused

4b. Were both of your eyes red or just one?

₂ Both ₁ Only one ₇₇₇ Don’t know ₈₈₈ Refused

4c. Was there any discharge? (Fluid or pus coming from your eye)

₀ No ₁ Yes ₇₇₇ Don’t know ₈₈₈ Refused

4d. When did you first notice your eyes were red?

__ __/__ __ __ /__ __ ₇₇₇ Don’t know ₈₈₈ Refused

D D M M M Y Y

4e. How many days did it last?

_________ days ₆₆₆ Still ongoing ₇₇₇ Don’t know ₈₈₈ Refused

5. If YES to joint swelling or pain, ask:

5a. When your joints were swollen or painful, which joints were affected? (Check all that apply)

₀ Neck ₁ Shoulders ₂ Back ₃ Hips ₄ Knees ₅ Ankles ₆ Toes

₇ Elbows ₈ Wrists ₉ Fingers ₇₇ Don’t know ₈₈ Refused

5b. When did you first notice your joints being swollen or painful?

__ __/__ __ __ /__ __ ₇₇₇ Don’t know ₈₈₈ Refused

D D M M M Y Y

5c. How many days did it last?

_________ days ₆₆₆ Still ongoing ₇₇₇ Don’t know ₈₈₈ Refused

6. In the past 2 weeks, did you have any of the following symptoms:

Nausea	0 No 1 Yes 77 Don’t know 88 Refused
Vomiting	0 No 1 Yes 77 Don’t know 88 Refused
Diarrhea	0 No 1 Yes 77 Don’t know 88 Refused
Coughing	0 No 1 Yes 77 Don’t know 88 Refused
Sneezing	0 No 1 Yes 77 Don’t know 88 Refused
Runny nose	0 No 1 Yes 77 Don’t know 88 Refused
Sore throat	0 No 1 Yes 77 Don’t know 88 Refused
Swollen lymph nodes	0 No 1 Yes 77 Don’t know 88 Refused
Dizziness or fainting	0 No 1 Yes 77 Don’t know 88 Refused
Numbness or tingling in your hands or feet	0 No 1 Yes 77 Don’t know 88 Refused
Ringing in your ears	0 No 1 Yes 77 Don’t know 88 Refused
Tiredness or fatigue	0 No 1 Yes 77 Don’t know 88 Refused
Muscle weakness	0 No 1 Yes 77 Don’t know 88 Refused
Muscle aches	0 No 1 Yes 77 Don’t know 88 Refused
Headache	0 No 1 Yes 77 Don’t know 88 Refused
Eye pain	0 No 1 Yes 77 Don’t know 88 Refused
Sensitivity to light	0 No 1 Yes 77 Don’t know 88 Refused
Itchy skin without a rash	0 No 1 Yes 77 Don’t know 88 Refused
Skin redness without a rash	0 No 1 Yes 77 Don’t know 88 Refused
Chest pain	0 No 1 Yes 77 Don’t know 88 Refused
Shortness of breath	0 No 1 Yes 77 Don’t know 88 Refused
Blood in your urine	0 No 1 Yes 77 Don’t know 88 Refused
Nosebleeds	0 No 1 Yes 77 Don’t know 88 Refused
Black, tarry stools	0 No 1 Yes 77 Don’t know 88 Refused
Constipation	0 No 1 Yes 77 Don’t know 88 Refused
[Women only:] Vaginal bleeding	0 No 1 Yes 77 Don’t know 88 Refused
[Women only:] Vaginal discharge	0 No 1 Yes 77 Don’t know 88 Refused
[Men only:] Blood in your semen	0 No 1 Yes 77 Don’t know 88 Refused

7. In the past 2 weeks, have you had any other unusual symptoms you would like to tell me about?

a. _________________________________________________________

b. __________________________________________________________

c. __________________________________________________________

For Post-Partum Women With a Live Born Infant

20. Are you currently breastfeeding?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

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