Partner Follow-up Medical History Visit Month Screening ID: Participant ID: Visit Date: Site Study Screening Number Site Study Couple I/P Chk dd mm yy Partner Follow up Medical History Items 1-19 are interviewer-administered questions and should be read aloud directly as written In the past 60 days, have you Yes No Don’t If yes, for how Ongoing experienced any of the know many days? following? No of days Yes No 1 Fever 2 Fatigue 3 Sore throat 4 Rash 5 Headache 6 Shortness of breath or cough 7 Abdominal pain 8 Nausea 9 Vomiting 10 Diarrhea 11 Excessive intestinal gas 12 Increased or decreased urinary output 13 Muscle weakness or pain 14 Swelling of the feet 15 pain 16 Bone pain 17 Bone fracture 18 Numbness or tingling in your hands or feet 19 Others 20 Since the last visit, has the Male only: participant been circumcised? Completed by: (initials/date) _________________________________________
Partner Follow-up Medical History Visit Month Screening ID: Site Study Screening Number Participant ID: Site Study Couple I/P Chk Visit Date: dd mm yy Partner Follow up Medical History Items 1-19 are interviewer-administered questions and should be read aloud directly as written In the past 60 days, have you experienced any of the following? Yes No Don’t know If yes, for how many days? Ongoing No of days Yes No 1 Fever 2 Fatigue 3 Sore throat 4 Rash 5 Headache 6 Shortness of breath or cough 7 Abdominal pain 8 Nausea 9 Vomiting 10 Diarrhea 11 Excessive intestinal gas 12 Increased or decreased urinary output 13 Muscle weakness or pain 14 Swelling of the feet 15 pain 16 Bone pain 17 Bone fracture 18 Numbness or tingling in your hands or feet 19 Others 20 Male only: Since the last visit, has the participant been circumcised? Completed by: (initials/date) _________________________________________
CRF2_Partner_Medical_History.docx