Ministry of Health

Directorate of Health Affairs

The prevalence, risk factors and outcome of Middle East Respiratory Syndrome – CoV (MERS-CoV) – Riyadh Region

Contact Initial Interview Questionnaire

Serial No.

Question Answer options Number of the selected answers

Comments

Medical section1. Date of interview (dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___

Type of health facility 1. MoH hospital2. MoH health center3. Non- MoH hospital4. Non- MoH health center5. Private Facility

2 Name of the health facility3 Region (write the name)4 ID of the patient ___ ___ ___/ ___ ___/ ___ ___ Composed of the

region number+ the health facility

number + the patient serial

number within the facility

5 Patient name6 Patient’s age (in years)

7 Patient’s date of birth(dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___8 Patient’s gender 1. Male

2. Female9 Complains/ symptoms:

Fever1.yes2. no

Rigors 1.yes2. no

Dry Cough 1.yes2. no

Productive cough 1.yes2. no

Sore throat 1.yes2. no

Runny nose 1.yes2. no

Shortness of breath 1.yes2. no

Fast breathing 1.yes2. no

Phlegm 1.yes2. no

Chest pain 1.yes2. no

Malaise 1.yes 2. no

Body aches 1.yes2. no

Headache 1.yes2. no

Diarrhea 1.yes

2. noVomiting 1.yes

2. nohad a contact with a person with similar condition within the last 14 days

1.yes2. no3. do not know

visited a healthcare facility as a patient or for any reason 1.yes2. no

Other (specify) 1.yes2. no

10 Date of onset of symptom(dd/mm/yyyy) ___ __ / ___ __ / ___ ___ __ ___Past medical history

11 Does the patient suffer from any of the following?

Diabetes? 1.yes2. no3. do not know

Asthma? 1.yes2. no3. do not know

Emphysema, chronic bronchitis or other chronic lung disease besides asthma?

1.yes2. no3. do not know

Kidney failure? 1.yes2. no3. do not know

Chronic liver disease such as hepatitis? 1.yes2. no3. do not know

Heart disease? 1.yes2. no3. do not know

High Blood Pressure 1.yes2. no3. do not know

History of cancer treatment in the last six months 1.yes2. no

Blood disorder such as chronic anemia? 1.yes2. no3. do not know

Were you taking corticosteroids in the last six months? 1.yes2. no

Do you regularly take medications? 1.yes2. no

Have you taken any traditional medications in the last six months

1.yes2. no3. do not know

If female, pregnant now? 1.yes2. no

3. do not know12 Are you currently tobacco smoke er(e.g., cigarettes, cigars,

shisha)?1. Yes2. no

If 2 go to 17

13 If yes, on average how much do you smoke 1. Not every day2. 1-2 times/day3. 3-10 times per day4. 11-20 times per day5. more than 20 times per day

14 Do you smoke sheesha? 1. Yes2. no

If 2 go to 17

15 If yes, on average how much do you smoke sheesha? 1. Several times per day2. Once a day3. Several times per week4. less than once per

week16 If yes, Do you share your tobacco (e.g., shisha)? 1.yes

2. no 3. do not know

17 If you do not currently smoke, where you a regular smoker in the past?

1. Yes2. no

If 2 go 19

18 If yes, when did you quit? (dd/mm/yyyy) __ __ / __ __ / __ ___ ___ ___19 Have you drunk an alcoholic beverage in the last 12 months? 1. Yes

2. noIf 2 go 21

20 If yes, on average how often have you drink alcoholic beverages in the last 12 months?

1. Rarely (less than once a month)

2. Monthly (at least once a month)

3. Weekly (at least once a week)

4. Daily21 Have you had contact with a person who had a

Respiratory illness/ diarrhoea/ vomiting during the previous 14 days?

1.yes2. no

3. do not know22 Medical Examination23 Weight (kg)24 Height (cm)25 Temperature (C°)26 Heart rate per minute27 Respiratory rate28 Blood pressure29 Assessment on Glasgow coma Scale 1. 1

2. 23. 34. 45. 56. 6

30 Chest auscultation 1. Abnormality detected2. No abnormality detected

(normal breath sounds)31 Interviewer’s name

SignatureNon-medical section

Background information32 Where does the patient work? 1. Office

2. Market (other than animal)3. Construction site4. Transportation5. Animal farm6. Animal market7. Slaughter house8. Butcher9. Veterinary facility10. Health care facility11. Student12. Not working13. Other

33 Marital status 1. Married2. Single3. Divorced4. Widow/widower

34 Educational level 1. Illiterate2. Primary3. Intermediate4. Secondary5. University and above

35 type of dwelling 1. Flat2. Detached

house/villa3. Other

36 Number of people living in house?37 Number of people living in house? Less than 1838 Number of people living in house? 18 and above39 Patient Mobile phone number40 House number41 Street name42 District/block name43 City/village name44 Next of kin mobile phone45 are any livestock (e.g. camels, sheep, goats, cattle, horses)

kept in or around your home1. Yes2. no

If 2 go 47

46 What type of animals: 1. Yes2. no

1. Camels 1. Yes2. No

2. Cattle 1. Yes2. No

3. Sheep 1. Yes2. no

4. Goats 1. Yes2. No

5. Horses 1. Yes2. No

6. Rabbits 1. Yes2. No

7. Poultry 1. Yes2. No

8. other 1. yes2. no

47 Do others living in your household (e.g., domestic help or relative) frequently visit or work on a farm or market where camels are kept or sold?

1. Yes2. no

Exposure history48 Is any of the following near your house?

Animal farm 1.yes2. No3. Do not know

Animal market 1.yes2. No3. Do not know

Animal race course 1.yes2. No3. Do not know

Veterinary facility 1.yes

2. No3. Do not know

Slaughter house 1.yes2. No3. Do not know

49 During the 14 previous days did you travel OUTSIDE of the country?

1.yes2. No

50 Country name51 During the 14 previous days, Did you travel to areas INSIDE

the country other than Riyadh?1.yes2. No

52 Province name53 During the 14 previous days, did you do any of the following54 Visit a farm with animals 1.yes

2. No55 Animals present at venue ?

1. camels 1.yes2. No

2. cattle 1.yes2. No

3. sheep 1.yes2. No

4. goat 1.yes2. No

5. horses 1.yes2. No

6. rabbits 1.yes2. No

7. poultry 1.yes2. No

8. other 1.yes2. No

56 Visit an animal market 1.yes2. No

If 2 go 58

57 Animals present at venue 1.yes2. No

1. camels 1.yes2. No

2. cattle 1.yes2. No

3. sheep 1.yes2. No

4. goat 1.yes2. No

5. horses 1.yes2. No

6. rabbits 1.yes2. No

7. poultry 1.yes2. No

8. other 1.yes2. No

58 Visit a slaughter house 1.yes2. No

If 2 go 60

59 Animals present at venue 1.yes2. No

1. camels 1.yes

2. No2. cattle 1.yes

2. No3. sheep 1.yes

2. No4. goat 1.yes

2. No5. horses 1.yes

2. No6. rabbits 1.yes

2. No7. poultry 1.yes

2. No8. other 1.yes

2. No60 Visit a race track 1.yes

2. NoIf 2 go to 62

61 Animals present at venue 1.yes2. No

1. camels 1.yes2. No

2. horses 1.yes2. No

62 During the 14 previous days, Did you have any direct contact with any animal carcasses, body fluids, secretions, urine or excrement?

1.yes2. No

63 During the 14 previous days, did you touch any items such as fences, textiles, machinery, clothing, or other physical objects in or around your home that may have had contact with animals

1.yes2. No

64 During the 14 previous days, did you have any contact with any animal bedding, stray of feed in or around your home?

1.yes2. No

65 During the 14 previous days, were in contact/handled with any sick animals

1.yes2. No

66 During the 14 previous days, did you personally handle any dead animals?

1.yes2. No

67 During the 14 previous days, At your home, did you do any of the following activitiesFeed animals? 1.yes

2. NoClean animal housing? 1.yes

2. NoClean farm equipment? 1.yes

2. NoSlaughter animals? 1.yes

2. NoAssist with the birth of animals 1.yes

2. NoMilk camels? 1.yes

2. NoKiss/hug camels? 1.yes

2. NoOther tasks? 1.yes

2. No68 During the 14 previous days, Have others living in your

household (e.g., domestic help or relative) had direct contact with camels in the past 2 weeks?

1.yes2. No3. do not know

FOOD EXPOSURES69 During the 14 previous days, how often on average did you

consume any of the following products?Fresh fruit 1. 7-5 days

2. 4-3 days3. 2-1 days4. never

Dried fruits 1. 7-5 days2. 4-3 days3. 2-1 days4. never

Raw dates 1. 7-5 days2. 4-3 days3. 2-1 days4. never

Fresh salad 1. 7-5 days2. 4-3 days3. 2-1 days4. never

raw milk products 1. 7-5 days2. 4-3 days3. 2-1 days4. never

Raw meat products 1. 7-5 days2. 4-3 days3. 2-1 days4. never

Camel urine 1. 7-5 days2. 4-3 days3. 2-1 days4. Never

Lab investigations70 Nasopharyngeal/ oropharyngeal sample taken 1. Yes

2. noIf 2 go 73

71 Date of sample (dd/mm/yyyy) __ __ / __ __ / __ __ __ ___72 Result of RT-PCR 1. negative

2. positive3. inconclusive

73 Treatment course 1. ambulatory treatment2. hospital admission (ward)3. ICU admission4. Assisted respiration

74 Complications 1. Pneumonia2. Acute renal failure3. ARDS4. Respiratory failure5. Cardiac failure6. Multi-organ failure7. Other

75 Outcome of disease 1. Cure2. Death3. Discharge against medical

advice4. death

76 Interviewer’s nameSignature