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
Seri
al
No.

Question

1. Date of interview (dd/mm/yyyy)

Type of health facility

2
3
4

Name of the health facility

Region (write the name)
ID of the patient

5
6
7

Patient name
Patients age (in years)
Patients date of birth(dd/mm/yyyy)

Patients gender

Complains/ symptoms:
Fever
Rigors
Dry Cough
Productive cough
Sore throat
Runny nose
Shortness of breath
Fast breathing
Phlegm
Chest pain
Malaise

Answer options

Number of
the selected
answers

Comment
s

Medical section
___ ___ / ___ ___ / ___ ___ ___
___
1. MoH hospital
2. MoH health center
3. Non- MoH hospital
4. Non- MoH health
center
5. Private Facility
___ ___ ___/ ___ ___/ ___ ___

___ ___ / ___ ___ / ___ ___ ___

___
1. Male
2. Female
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes

Composed of
the region
number+ the
health facility
number + the
patient serial
number within
the facility

Body aches
Headache
Diarrhea
Vomiting
had a contact with a person with similar
condition within the last 14 days
visited a healthcare facility as a patient or for
any reason
Other (specify)
10

Date of onset of symptom(dd/mm/yyyy)

11

Past medical history

Does the patient suffer from any of the following?
Diabetes?
Asthma?
Emphysema, chronic bronchitis or other chronic
lung disease besides asthma?
Kidney failure?
Chronic liver disease such as hepatitis?
Heart disease?
High Blood Pressure
History of cancer treatment in the last six months
Blood disorder such as chronic anemia?
Were you taking corticosteroids in the last six
months?
Do you regularly take medications?
Have you taken any traditional medications in
the last six months
If female, pregnant now?

12

Are you currently tobacco smoke er(e.g.,

cigarettes, cigars, shisha)?

2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
1.yes
2. no
3. do not know
1.yes
2. no
1.yes
2. no
___ __ / ___ __ / ___ ___ __
___

1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1.yes
2. no
1.yes
2. no
3. do not know
1.yes
2. no
1.yes
2. no
1.yes
2. no
3. do not know
1.yes
2. no
3. do not know
1. Yes
2. no

If 2 go to 17

13

If yes, on average how much do you smoke

14

Do you smoke sheesha?

15

If yes, on average how much do you smoke

sheesha?

16

If yes, Do you share your tobacco (e.g., shisha)?

17

If you do not currently smoke, where you a

regular smoker in the past?
If yes, when did you quit? (dd/mm/yyyy)
Have you drunk an alcoholic beverage in the last
12 months?
If yes, on average how often have you drink
alcoholic beverages in the last 12 months?

18
19
20

21

22
23
24
25
26
27
28
29

Have you had contact with a person who had a

Respiratory illness/ diarrhoea/ vomiting during
the previous 14 days?
Medical Examination
Weight (kg)
Height (cm)
Temperature (C)
Heart rate per minute
Respiratory rate
Blood pressure
Assessment on Glasgow coma Scale

30

Chest auscultation

31

Interviewers name
Signature

1.
2.
3.
4.
5.

Not every day

1-2 times/day
3-10 times per day
11-20 times per day
more than 20 times
per day
1. Yes
2. no
1.
Several times per
day
2.
Once a day
3.
Several times per
week
4.
less than once per
week
1.yes
2. no
3. do not know
1. Yes
2. no
__ __ / __ __ / __ ___ ___ ___
1. Yes
2. no
1. Rarely (less than once
a month)
2. Monthly (at least once
a month)
3. Weekly (at least once
a week)
4. Daily
1.yes
2. no
3. do not know

1.
2.
3.
4.
5.
6.
1.
2.

1
2
3
4
5
6
Abnormality detected
No abnormality
detected (normal
breath sounds)

Non-medical section
32

Background information
Where does the patient work?

1. Office
2. Market (other than
animal)
3. Construction site

If 2 go to 17

If 2 go 19

If 2 go 21

33

Marital status

34

Educational level

35

type of dwelling

36
37
38
39
40
41
42
43
44
45

Number of people living in house?

Number of people living in house? Less than 18
Number of people living in house? 18 and above
Patient Mobile phone number
House number
Street name
District/block name
City/village name
Next of kin mobile phone
are any livestock (e.g. camels, sheep, goats,
cattle, horses) kept in or around your home
What type of animals:

46

1. Camels
2. Cattle
3. Sheep
4. Goats
5. Horses
6. Rabbits
7. Poultry
8. other
47

48

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?
Exposure history
Is any of the following near your house?
Animal farm

4. Transportation
5. Animal farm
6. Animal market
7. Slaughter house
8. Butcher
9. Veterinary facility
10. Health care facility
11. Student
12. Not working
13. Other
1. Married
2. Single
3. Divorced
4. Widow/widower
1. Illiterate
2. Primary
3. Intermediate
4. Secondary
5. University and
above
1. Flat
2. Detached
house/villa
3. Other

1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.

1. Yes
2. no
1. Yes
2. no
Yes
No
Yes
No
Yes
no
Yes
No
Yes
No
Yes
No
Yes
No
yes
no
1. Yes
2. no

1.yes

If 2 go 47

Animal market
Animal race course
Veterinary facility
Slaughter house
49

54

During the 14 previous days did you travel

OUTSIDE of the country?
Country name
During the 14 previous days, Did you travel to
areas INSIDE the country other than Riyadh?
Province name
During the 14 previous days, did you do any of
the following
Visit a farm with animals

55

Animals present at venue ?

50
51
52
53

1. camels
2. cattle
3. sheep
4. goat
5. horses
6. rabbits
7. poultry
8. other
56

Visit an animal market

57

Animals present at venue

1. camels
2. cattle
3. sheep
4. goat
5. horses
6. rabbits

2. No
3. Do not
1.yes
2. No
3. Do not
1.yes
2. No
3. Do not
1.yes
2. No
3. Do not
1.yes
2. No
3. Do not
1.yes
2. No

know
know
know
know
know

1.yes
2. No

1.yes
2. No

1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No

If 2 go 58

7. poultry
8. other
58

Visit a slaughter house

59

Animals present at venue

1. camels
2. cattle
3. sheep
4. goat
5. horses
6. rabbits
7. poultry
8. other

60

Visit a race track

61

Animals present at venue

1. camels
2. horses

62

63

64

65
66
67

During the 14 previous days, Did you have any

direct contact with any animal carcasses, body
fluids, secretions, urine or excrement?
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
During the 14 previous days, did you have any
contact with any animal bedding, stray of feed in
or around your home?
During the 14 previous days, were in
contact/handled with any sick animals
During the 14 previous days, did you personally
handle any dead animals?
During the 14 previous days, At your home, did
you do any of the following activities
Feed animals?
Clean animal housing?
Clean farm equipment?
Slaughter animals?
Assist with the birth of animals

1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No

1.yes
2. No
1.yes
2. No
1.yes
2. No

1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes

If 2 go 60

If 2 go to 62

2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
1.yes
2. No
3. do not know

Milk camels?
Kiss/hug camels?
Other tasks?
68

69

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?
FOOD EXPOSURES
During the 14 previous days, how often on
average did you consume any of the following
products?
Fresh fruit

Dried fruits

Raw dates

Fresh salad

raw milk products

Raw meat products

Camel urine

70

Lab investigations
Nasopharyngeal/ oropharyngeal sample taken

71
72

Date of sample (dd/mm/yyyy)

Result of RT-PCR

73

Treatment course

__ __ /
1.
2.
3.
1.
2.
3.
4.

74

Complications

1.
2.
3.
4.
1.
2.
3.
4.

7-5 days
4-3 days
2-1 days
never
7-5 days
4-3 days
2-1 days
never

1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.

7-5 days
4-3 days
2-1 days
never
7-5 days
4-3 days
2-1 days
never
7-5 days
4-3 days
2-1 days
never
7-5 days
4-3 days
2-1 days
never
7-5 days
4-3 days
2-1 days
Never

1. Yes
2. no
__ __ / __ __ __ ___
negative
positive
inconclusive
ambulatory treatment
hospital admission
(ward)
ICU admission
Assisted respiration
1. Pneumonia
2. Acute renal failure
3. ARDS

If 2 go 73

75

Outcome of disease

1.
2.
3.
4.

76

Interviewers name
Signature

4. Respiratory failure
5. Cardiac failure
6. Multi-organ failure
7. Other
Cure
Death
Discharge against
medical advice
death