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
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