"General Enteric Diseases Interview Form - Salmonella & Campylobacter" - Connecticut

General Enteric Diseases Interview Form - Salmonella & Campylobacter is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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  • Released on January 1, 2019;
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Download "General Enteric Diseases Interview Form - Salmonella & Campylobacter" - Connecticut

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GENERAL ENTERIC DISEASES INTERVIEW FORM
SALMONELLA AND CAMPYLOBACTER
Version 01-2019
Reporting Health Department
Completed by:
LHD:
Phone:
Date of first interview attempt:
/
/
Date interview completed:
/
/
Case was interviewed
Case was not interviewed because:
Unreachable
Refused
No working phone
Other________________________
NOTE: Even if case could not be interviewed, please complete above information and enter into CTEDSS or fax this page to the DPH
Epidemiology Program at 860-509-7910.
Case Information
Last name:
First Name:
Street:
City:
Zip:
Phone: (
)
-
DOB:
/
/
Age:
Sex:
M
F
Other____________
Date specimen collected:
/
/
Source:
Stool
Blood
Urine
Other________________
Pathogen:
Laboratory:
Before we ask about your illness, we would like to get some information on your race and ethnicity.
What is your race?
White
Black
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Other____________________
Unknown
Are you of Hispanic background?
Yes
No
Unknown
Illness Information
Yes
No
Unk
If yes, additional details:
Did you have any symptoms associated with
Date/time of onset:
/
/
:
AM
PM
this illness?
Vomiting
Date/time of onset:
/
/
:
AM
PM
Diarrhea
Date/time of onset:
/
/
:
AM
PM
Number of days diarrhea lasted:
Bloody Diarrhea
Fever
Highest temperature:
Are you still experiencing symptoms?
If no, total number of days illness lasted:
Yes
No
Unk
If yes, additional details:
Were you hospitalized?
Hospital name:
(Inpatient only, not just ED visit)
Admit date:
/
/
Discharge date:
/
/
During any part of the hospitalization, did
you stay in an Intensive Care Unit (ICU) or
a Critical Care Unit (CCU)?
Outcome:
Survived
Died
Occupation and Risk Factor Information
What is your occupation?
Yes
No
Unk
If yes, specify name and address of the facility
Do you work or volunteer in a facility that
prepares/serves/handles/sells food?
Provide direct patient care outside the home
Work in day care setting
Attend day care setting
Can you tell us about other household members, their ages, occupation, and whether they have been ill with a similar
illness:
Name
Relationship
Age
Occupation
Ill
If yes, onset date and symptoms
Yes
No
Yes
No
Yes
No
Yes
No
NOTE: If case or household contacts are involved in high risk occupations/activities, implement appropriate control
recommendations. Refer to the “Reportable Infectious Diseases Reference Manual”.
1
GENERAL ENTERIC DISEASES INTERVIEW FORM
SALMONELLA AND CAMPYLOBACTER
Version 01-2019
Reporting Health Department
Completed by:
LHD:
Phone:
Date of first interview attempt:
/
/
Date interview completed:
/
/
Case was interviewed
Case was not interviewed because:
Unreachable
Refused
No working phone
Other________________________
NOTE: Even if case could not be interviewed, please complete above information and enter into CTEDSS or fax this page to the DPH
Epidemiology Program at 860-509-7910.
Case Information
Last name:
First Name:
Street:
City:
Zip:
Phone: (
)
-
DOB:
/
/
Age:
Sex:
M
F
Other____________
Date specimen collected:
/
/
Source:
Stool
Blood
Urine
Other________________
Pathogen:
Laboratory:
Before we ask about your illness, we would like to get some information on your race and ethnicity.
What is your race?
White
Black
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Other____________________
Unknown
Are you of Hispanic background?
Yes
No
Unknown
Illness Information
Yes
No
Unk
If yes, additional details:
Did you have any symptoms associated with
Date/time of onset:
/
/
:
AM
PM
this illness?
Vomiting
Date/time of onset:
/
/
:
AM
PM
Diarrhea
Date/time of onset:
/
/
:
AM
PM
Number of days diarrhea lasted:
Bloody Diarrhea
Fever
Highest temperature:
Are you still experiencing symptoms?
If no, total number of days illness lasted:
Yes
No
Unk
If yes, additional details:
Were you hospitalized?
Hospital name:
(Inpatient only, not just ED visit)
Admit date:
/
/
Discharge date:
/
/
During any part of the hospitalization, did
you stay in an Intensive Care Unit (ICU) or
a Critical Care Unit (CCU)?
Outcome:
Survived
Died
Occupation and Risk Factor Information
What is your occupation?
Yes
No
Unk
If yes, specify name and address of the facility
Do you work or volunteer in a facility that
prepares/serves/handles/sells food?
Provide direct patient care outside the home
Work in day care setting
Attend day care setting
Can you tell us about other household members, their ages, occupation, and whether they have been ill with a similar
illness:
Name
Relationship
Age
Occupation
Ill
If yes, onset date and symptoms
Yes
No
Yes
No
Yes
No
Yes
No
NOTE: If case or household contacts are involved in high risk occupations/activities, implement appropriate control
recommendations. Refer to the “Reportable Infectious Diseases Reference Manual”.
1
Did you travel to any other states in the 7 days before illness?
Yes
No
Unknown
City/State:
Depart CT:
/
/
Return CT:
/
/
City/State:
Depart CT:
/
/
Return CT:
/
/
Did you travel outside of the United States in the 7 days before illness?
Yes
No
Unknown
Country:
Depart CT:
/
/
Return CT:
/
/
Country:
Depart CT:
/
/
Return CT:
/
/
In the 6 months before your illness began, did you travel outside of the United States?
Yes
No
Unknown
If yes, list countries?
In the 6 months before your illness began, did any member of your household travel outside of the United States?
Yes
No
Unknown
If yes, list countries?
Did you attend any large parties or gatherings (parties, fairs, festivals) in the 7 days before illness?
Yes
No
Unknown
Event:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Did you eat foods from any restaurants in the 7 days before illness?
Yes
No
Unknown
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Where did you purchase groceries eaten in the 7 days before illness (including farmer’s markets, home delivery service)
Store Name
City
Special Diet
Yes
No
Unk
If yes, specify/describe, brand/type:
Food allergies that prevent you from eating certain foods
Vegetarian or vegan diet
Special or restricted diet (weight-loss, cultural, religious)
If infant, formula or baby food
Did you have any of the following exposures in the 7 days before your illness?
(Note for interviewer: If yes, please ask any listed follow-up questions)
Water-Related Exposure
Yes
No
Unk
If yes, where:
Drink untreated water (natural spring, pond, lake, river)
Swim, wade, or play in untreated water (ocean, lake,
pond, river, stream, or natural spring)
Swim, wade, or play in treated water (pool, hot tub/spa,
fountain, splash pad, or waterpark with treated or
chlorinated water)
Animal Contact
Yes
No
Unk
If yes, where/type of animal:
Dog
Is dog a puppy (<1 year)?
Cat
Other pet mammals (rodent, ferrets, rabbits, guinea pigs)
Reptiles/Amphibians (turtles, frogs, lizards)
Other pets (fish, hermit crabs)
Live poultry (chicken, turkey)
Cattle, goats, sheep
Pigs
Visit, work, or live on farm/ranch/petting zoo
Ill Contacts
Yes
No
Unk
If yes, who:
Household or close contact with diarrhea
2
The food exposure section below can be omitted if case traveled internationally during the entire 7-day period before onset. If case
was out of the country only for part of the 7-day period before onset, please collect information on foods eaten while in US.
Did you eat the following items in the 7 days before your illness?
(Note for interviewer: If yes, please ask any listed follow-up questions and specify brand/type, where purchased/eaten.)
Meats and Seafood
Yes
No
Unk
If yes, food details:
Chicken or foods containing chicken (deli, ground, jerky)
Any chicken at home bought fresh?
Any chicken at home bought frozen?
Was chicken ground?
Turkey or foods containing turkey (deli, ground, jerky)
Was turkey ground?
Beef or foods containing beef (deli, ground, jerky)
Was beef ground?
Was ground beef undercooked or raw?
Pork or foods containing pork (deli, ground, jerky)
Lamb or mutton
Veal
Raw or undercooked liver
Liver pate
Game meat (bison, elk, rabbit, venison)
Fish or fish products
Was fish undercooked or raw (sushi)?
Shellfish (crab, shrimp, oysters, clams)
Was shellfish undercooked or raw?
Eggs and Dairy
Yes
No
Unk
If yes, food details:
Eggs
Were eggs undercooked or raw?
Foods made with raw eggs (mayonnaise, cookie dough)
Unpasteurized or raw milk
Other raw dairy products (cheese, yogurt, ice cream)
Any dairy products
Fresh, Raw Produce
Yes
No
Unk
If yes, food details:
Cantaloupe
Watermelon
Berries, specify type:
Lettuce, specify type:
Was lettuce prepackaged/bagged?
Was lettuce whole head or loose leaf?
Raw spinach
Raw tomatoes, specify type:
Cucumbers, specify type:
Sprouts, specify type:
Fresh herbs, specify type:
Other fruits and vegetables (fresh, dried, frozen)
Other Foods
Yes
No
Unk
If yes, food details:
Any unpasteurized or raw juices, ciders, smoothies
Raw nuts (not roasted, processed)
Peanut butter/ peanut butter-containing products (crackers)
Frozen entrees (pot pies, stuffed chicken products, pizza)
3
The following questions should be asked for all Salmonella cases and Campylobacter cases with isolates available.
I’d like to now ask a few questions about your medical history and treatments you may have received. Some of these
questions may not apply to you, but we need to ask them of everybody. Your response can help us better understand these
infections and how to better prevent them, especially in vulnerable populations.
Comorbidities
Yes
No
Unk
If yes, additional details:
In the 6 months before your illness began, were you
diagnosed or treated for cancer (including
leukemia/lymphoma)?
In the 6 months before your illness began, were you
diagnosed or treated for diabetes?
In the 6 months before your illness began, did you have
abdominal surgery (e.g. removal of appendix or
gallbladder, or any surgery of the stomach or large
intestines)?
Do you have any underlying medical conditions or are
Describe:
you immunocompromised?
Medications
Yes
No
Unk
If Yes, additional details:
Did you take antibiotics for this illness?
List antibiotic name(s):
Date started:
Date ended:
In the 30 days before your illness began, did you take
List antibiotic name(s):
any antibiotics?
In the 30 days before your illness began, did you take
List antacid name(s):
any form of antacid (e.g. medications to block acid such
as those taken for heartburn, indigestion, or acid reflex,
including proton-pump inhibitors)?
In the 30 days before you/ illness began, did you take a
Describe:
probiotic (these can take the form of pills, powders,
yogurts, and other fermented dairy products that contain
“live and active” cultures)?
That completes the interview. Thank you for taking the time to answer these questions. Your responses may be helpful
in preventing others from becoming sick.
Antibiotic Names
Amoxicillin
Amoxicillin/Clavulanate
Ampicillin
Augmentin
Azithromycin
Bactrim
Biaxin
Ceclor
Cefaclor
Ceftrin
Cefixime
Cefuorixime
Cefzil
Cefprozil
Cephalexin
Cephradine
Ciprofloxacin/Cipro
Clarithromycin
Dapsone
Doxycycline
Duricef
Erythromycin
Erythromycin/sulfisoxizole
Flagyl
Floxin
Keflex
Keftab
Levofloxacin
Levoquin
Metronidazole
Norfloxacin/Norflox
Ofloxacin/Oflox
Pediazole
Penicillin/Pen VK
Septra
Suprax
Tetracycline
Trimox
Trimethoprim/Sulfa
Zithromax/Z-Pak
Antacid Names
Aluminium hydroxide
Ami-Lac
Amphojel
Axid
Calcium carbonate
Cal-Guest
Caltrate
calcium-based supplements
Dexilant
Dialume
Di-Gel
Gas-X with Maalox
Gaviscon
Gelusil
Genaton
Isopan
Maalox / Maox
Magaldrate
Magnesium Hydroxide
Masanti
Mi-Acid
Milantex
Milk of Magnesia
Mintox
Mylanta
Nexium
Nizatidine
Os-Cal
Oysco
Oyster (shell) calcium
Pepcid
Pepto Children's
Prevacid
Prilosec
Protonix
Ri-Mag
Riopan
Rolaids
Ron-Acid
Rulox
Tagamet
Tempo
Titralac
Tums
Zantac
Zegerid
COMMENTS:_________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please enter interview data into CTEDSS or fax to DPH Epidemiology Program at 860-509-7910. Thank you.
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