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Date questionnaire completed (dd/mm/yyyy)
Questionnaire completed by ...... (name, profession, department, hospital, address, telephone,
fax)
Person interviewed (delete as appropriate): Patient themselves, Family Member, Friend/associate,
Hospital Staff
A) Patient identification
Patients name
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Family name:
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First name:
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Date of birth
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(dd/mm/yyyy)
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Sex
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M / F
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Residential Address
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House number,
Street name
Town/municipality.
Postal code (if appropriate):
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Telephone no.:
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Contact person details
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Address:
Telephone no.:
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Work address
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Employer's contact details
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Hospital name and address
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Date of Hospitalisation
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(dd/mm/yyyy)
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Doctor's name
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Doctor's contact details
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Address:
Telephone no.:
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Date of legionellosis symptoms onset (dd/mm/yyyy)
Period of questioning (ideally 14 days before onset date of symptoms)
from dd/mm/yyy/ to dd/mm/yyyy
B) Confirmation of diagnosis
Case of: Legionnaires' disease □ , Pontiac fever □ or asymptomatic
Legionella infection □
Other clinical features: Chest pains □, Confusion □, Cough □,
Diarrhoea □, Lethargy □, Shortness of breath□, other (please state ….)
Diagnostic test
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Done?
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Test Result
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Not yet known
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Positive
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Negative
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Strong clinical suspicion of pneumonia
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Not applicable
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Not applicable
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□
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X-ray confirmation of pneumonia
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□
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□
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Urinary antigen
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□
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□
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Culture - respiratory specimen
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□
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□
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□
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□
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Serology
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Single titre serum
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□
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□
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□
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Paired serum
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□
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Microbiological detail:
Species
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Serogroup: (if applicable)
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Subgroup: (if applicable and known)
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Sequence type: (if known)
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Clinical Risk factors: cancer □ (please state which
type................................), corticosteroids □, other immunosuppressants □,
smoking □, diabetes □, chronic pulmonary disease (chronic bronchitis,
emphysema….) □, cardiovascular disease □, renal failure □, dialysis
□, transplant □, other (please state ....................)
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Still ill
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Dead
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Recovered
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Unknown
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Current situation
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Date of death (dd/mm/yyyy)
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Date of discharge (dd/mm/yyyy)
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30 day follow up
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Date of death (dd/mm/yyyy)
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Date of discharge (dd/mm/yyyy)
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C) Exposures
Do you have an idea of where you may have contracted Legionellosis? yes □
no □ don't know □
If yes, please state where, when and how
1) Overnight stays outside of the house
In the 14 days BEFORE the first day of your illness, did you spend a night away from the
residential address given above? yes □ no □ don't know □
If yes, was this spent at a:
Hospital yes □ no □ don't know □
Other health care institution yes □ no □ don't know □
Hotel yes □ no □ don't know □
Campsite yes □ no □ don't know □
Apartment or cottage yes □ no □ don't know □
Ship yes □ no □ don't know □
Private accommodation yes □ no □ don't know □
Second home yes □ no □ don't know □
Other yes □ no □ don't know □
If yes, please give details:
Name and address of temporary accommodation (including room number if
known)*
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Town or resort
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Country
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Purpose of stay, if appropriate (i.e. visitor, patient, tourist,
business)
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Dates of stay (dd/mm/yyyy)
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Possible contact with aerosols other than designated bathroom**
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From
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To
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* If temporary accommodation is a hospital or healthcare institution then check they have not
been transferred from another similar institution in the past 14 days and ensure this sites
details are captured too.
** possible sources of contamination include: any system that might generate aerosols, for
example but not limited to: water systems (showers), air cooling systems and cooling towers,
whirlpool/spa/hot tubs/thermal baths, aerosol respiratory equipment, thermal waters, decorative
fountains, biological treatment plants and cooling towers)
2) Other visits to Hospital settings
In section 1 you told me about any overnight stays in hospital or other health care
institution and where and when these occurred. Could you now tell me of any day trips in the
fourteen days BEFORE the first day of your illness, as patient or visitor in a hospital or
similar institution?
Date of visit (dd/mm/yyyy)
Type of ward in which you were visitor/patient:
Name of institution
Room no.
Address:
Postal code (if relevant):
Did you visit other hospitals in the 14 day period not already stated above or in section
1? If so please give details?
If yes, please give details:
Name of hospital before transfer
Date of stay from (dd/mm/yyyy) to (dd/mm/yyyy)
When was your last visit to a hospital? (dd/mm/yyyy)
3) Possible sources at work or during regular activity
Occupation (or activity if retired):
Name and address of place of work (or place of regular activity):
During the 14 days before your first day of illness , have you taken one or more showers
at your place of work? yes □ no □ don't know
□
Do you work with pressurised water (water gun, cutting fluid)? yes □ no
□ don't know □
If yes, please state:
At work, are you in contact with an air cooling system (air conditioning system, cooling
tower)? yes □ no □ don't know □
If yes, please state:
If so is your air conditioning associated with a cooling tower? yes □ no
□ don't know □
Are there temporary remedial works (i.e. road etc) near to your work? yes
□ no □ don't know □
At approximately what distance from your place of work?
How do you make the journey between home and work?
On foot □, by car □, public transport □, other (example car plus train), don't
know □
Can you share details about your normal route to work from place of residence?
(Roads normally used, extraordinary deviations from typical route in 14 days prior to onset of
symptoms)
Travelling to work, do you pass (f yes please provide specific geographical detail about
areas and/or roads):
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through urban areas? yes □ no □ don't know
□
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industrial areas? yes □ no □ don't know
□
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biological treatment plants? yes □ no □ don't
know □
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temporary works (such as road maintenance etc)? yes □ no
□ don't know □
If yes, what type (construction, excavation)?
4) Leisure activities
During the 14 days before your first day of illness, have you done any
gardening? yes □ no □ don't know □
If yes, what type?
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Watering with hose pipe: yes □ no □ don't know
□
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Handling soil or compost: yes □ no □ don't know
□
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Have you used a water spray for treating plants (inside or outside)? yes
□ no □ don't know □
During the 14 days before your first day of illness, have you washed your car
yes □ no □ don't know□
If yes, was this at home or at a car-wash? If car-wash,
please state place and date:
During the 14 days before your first day of illness, have you been in contact with water
systems such as:
System
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Yes
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No
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Not sure
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If yes, address and date of
contact
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Pressure/jet washers
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Water jets, fountains
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Showers away from residential and work setting
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Water sports (swimming, canoeing)
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Aquagym
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Jacuzzi/spa pool/thermal bath
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Sprayer or humidifier in public areas (service station, train station..)
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During the 14 days, have you visited
Venue
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Yes
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No
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Not sure
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If yes, addresses and dates of
contact
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A sports club
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A sports stadium
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A swimming pool
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Public baths
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Dentist
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Petrol Service Station
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A park with water games
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An exhibition or fair with water
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Any other place with water emission
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Any place where thermal water has been aerosolised?
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A shopping centre
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Other shopping outlet
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An industrial unit with cooling towers
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A Biological treatment plant
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5) Person's residence
Do you live in a: house □, block of flats □, Other □ please
state:
If you live in a block of flats, is the hot water production of your home:
individual □, collective □, not known □
Is the source of your domestic water: municipal □, individual
(e.g. well) □, mixed □, not known □
If individual, is it from: a well □ a channel?
□ don't know □
In your bathroom, is the hot water from:
- Storage tank yes □ no □ don't know □
- Instant production (boiler, immersion) yes □ no □ don't know
□
- Other yes □ no □ if yes, please state:
Do you have air-conditioning at home yes □ no □ don't know □
If yes, was it used for at least one day during this period? yes □ no □ don't
know □
Have you used a nebuliser at home? yes □ no □ don't know □
During the period, have you had any cuts to your water supply to your house? yes
□, no □, not known □
Have there been any works/construction/excavation near to your house (i.e. same
street)?
If yes, which type (construction/excavation)?
And at what distance from your house (or give road name)?
Is your house near an industrial unit which produces fumes? yes □, no
□, not known □
If yes, which factory and what does it produce?: Town:
6) Summary table of cases activities in the 14 days before onset of symptoms. Please complete as
accurately as possible
Day
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DATE (count back 14 days from start of illness)
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MORNING
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AFTERNOON
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EVENING
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14
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13
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12
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11
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10
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9
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8
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7
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6
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5
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4
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3
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2
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1
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Start
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D) Epidemiological links to other cases
Do you know people near to you who have recently been hospitalised with
pneumonia? yes □, no □, not known □
If yes, please state which hospital
(Interviewer/outbreak control team to complete following parts, if necessary)
Have any other legionellosis cases visited the same places or areas within a period of 2
years? yes □ no □
If yes, give case numbers: date of symptom onset:
(dd/mm/yyyy)
Summary of common areas/numbers exposed
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Number exposed
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Number of people with possible symptoms of pneumonia
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Number of confirmed cases of Legionnaires' disease
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Living/staying at same residence
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Visiting residence
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Working at same site
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Staying/visiting same temporary location (hospital/leisure sites etc)
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Other notes/comments:
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