| Appendix III:B-3. Health Surveillance Questionnaire -
Legionellosis |
We at, ________________________(identify agency) are investigating a cluster of respiratory infections at
_________________________(location), Records show that you took sick leave for three consecutive days or more. We would like
to ask a few questions about your work absence.
- Name: (last)____________________, (first)__________________
Age:______
Gender: ______
Work Location: ____________________
Home Phone:___________
Work Phone:________________________
- Dates of absence(s):______________________________________
- Stated reason for absence:________________________________
Ask about the following symptoms:
- Fever: Yes____ No____ Unsure____
If yes, highest temperature _____.
- Cough: Yes____ No ____. If yes, was the cough productive? Yes____ No____
- Headache: Yes_____ No_____
- Diarrhea: Yes_____ No_____
- Shortness of breath: Yes ____ No ____
- Chest pain: Yes ____ No ____
- Did you see a physician about these symptoms? Yes ___ No ___
Was a chest x-ray taken? Yes_____ No_____
Were you tested for legionellosis? Yes_____ No_____ Don't Know______
Were you diagnosed as having pneumonia? Yes _____ No _____. If no, what was the diagnosis? _____________________________________
Physician's name:______________________ Phone:_____________
Physician's Address:______________________________________
- Were you admitted to a hospital? Yes ____ No ____
If yes, which hospital? ________________________(name) ____________________(location)
Admission Date: _____/______/______
Date released: _____/______/______
- Interviewer:________________________________
Date:_____/______/______
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