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Cholera in Rwenshama - Page 1

Cholera in Rwenshama (EpiInfo Tutorial)

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QUESTIONNAIRES: CHOLERA CASES IN RWENSHAMA - 2001

Questionnaire No. (Required) 1 (###) Date (Required) 22-05-2001 (dd-mm-yyyy)

PERSONAL SPECIFICATION
Name

Age 34 Sex (Required) Select one:

Male

(##)

(_) Male (_) Female

Occupation soldier Education Level Select one:

secondary (_) Nil (_) Primary 1-4 (_) Primary 5-7 (_) Secondary (_) Tertiary

Village Select one:

Rwenshama (_) Rwenshama (_) Rwebinyoni (_) Ncwera

No. of People in Household 1 (#) Ill? (Required)

Yes

(_) Yes (_) No

If yes, date of onset 06-05-2001 (dd-mm-yyyy) (If not ill, skip to page 3 - Risk Factors)

039C239B-3FAF-D945-89E6-53BDCD1DA0A6

Cholera in Rwenshama - Page 2

Illness
Symptoms of illness
Select all that apply Diarrhoea Vomiting Cramps in abdomen Cramps in arms and legs Duration of illness in days before reporting for treatment at the health unit 2 (#) Treatment given at home before reporting metronidazole

Signs on Presentation at Health Unit

Dehydration Select one:
severe (_) Nil (_) Some (_) Severe

Fever
No

(_) Yes (_) No

Other (specify) weak

Treatment given at health unit

Select all that apply Oral Fluids I-V Fluids Tetracycline Co-trimoxazole Other (specify) metronidazole Outcome Select one:
improved (_) Died (_) Improved

Cholera in Rwenshama - Page 3

RISK FACTORS
History of eating outside home within past 5 days
No

(_) Yes (_) No

If yes, specify Select one:

(_) hotel (_) bar (_) neighbor (_) roadside

Did you take any of these foods in the last five days?
Hot matooke Cold matooke Hot sweet potatoes Cold sweet potatoes Hot rice Cold rice Hot irish potatoes Cold irish potatoes Hot posho Cold posho Hot mandazi Cold mandazi Hot cassava Cold cassava Hot beans Cold beans Hot peas Cold peas Hot meat Cold meat Hot milk Cold milk Hot fish Cold fish Obushera Sugar cane Sweet bananas Salads (raw cabbage, tomatoes)

Cholera in Rwenshama - Page 4

RISK FACTORS page 2

Diarrhoea contact at home in the last five days
No

(_) Yes (_) No

Availability of pit latrine in home

Yes

(_) Yes (_) No

If yes, what is the state of the latrine Select one:

clean (_) clean (_) dirty

Where does household get its water? Select one:

lake (_) lake (_) river

How does household prepare its drinking water? Select one:

not boiling (_) boiling (_) not boiling

Does household have facility for washing after latrine use?

No

(_) Yes (_) No

Is there a rack for drying plates in the home?

No

(_) Yes (_) No

Cleanliness around the home Select one:

poor (_) good (_) fair (_) poor

Did you attend health education sessions on diarrhoea or cholera in the last 2 years?
No

(_) Yes (_) No

If yes, who gave it?

In your opinion, how does one get cholera?

dirty home, drinking unboiled water

Created by: EpiSuccess Date: Feb 01, 2009

Form 10

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