General Survey Module B: Health Status Now I would like to ask you some questions about any symptoms you may have experienced after the incident. Within 24 hours of the incident, did you have any symptoms of an illness? Yes No Go to next module I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom. Did you Were you Was your Are you still experience experiencing [Symptom] experiencing [Symptom] within [Symptom] worse after the [Symptom]? 24-hours of the before the incident? Repeat i for incident? If yes, incident? If Continue to iv (if next go to ii. If no, yes, go to iii. If listed); symptom. repeat i for next no, go to iv. otherwise, repeat symptom. i for next symptom. Symptom Yes No Yes No Yes No Yes No Irritation/pain/ burning of eyes Increased tearing Blurred vision/double vision Runny nose Burning nose or throat Burning lungs Increased salivation Ringing of the ears Difficulty swallowing Odor on breath (Gasoline or other, specify) Headache Dizziness or lightheadedness Loss of consciousness/fainting Seizures Numbness, pins and needles, or funny feeling in arms or legs Confusion Difficulty concentrating
General Survey Module B: Health Status Now I would like to ask you some questions about any symptoms you may have experienced after the incident. Within 24 hours of the incident, did you have any symptoms of an illness? Yes No Go to next module I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom. Did you experience [Symptom] within 24-hours of the incident? If yes, go to ii. If no, repeat i for next symptom. Were you experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv. Was your [Symptom] worse after the incident? Continue to iv (if listed); otherwise, repeat i for next symptom. Are you still experiencing [Symptom]? Repeat i for next symptom. Symptom Yes No Yes No Yes No Yes No Irritation/pain/ burning of eyes Increased tearing Blurred vision/double vision Runny nose Burning nose or throat Burning lungs Increased salivation Ringing of the ears Difficulty swallowing Odor on breath (Gasoline or other, specify) Headache Dizziness or lightheadedness Loss of consciousness/fainting Seizures Numbness, pins and needles, or funny feeling in arms or legs Confusion Difficulty concentrating