Form 0920-25AU Follow-up Clinical Survey

Form Approved

OMB No. 0920-1446

Exp. Date: 3/31/2025

ATTACHMENT 4. FOLLOW-UP ABBREVIATED CLINICAL SURVEY

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 (0920-1446).

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.

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