The Heather Preen Trust
		E.coli OUT Questionnaire
Home Page Trust Projects Newsletter Outbreak Reports Research Questionnaire How To Contact Us		Please complete a separate questionnaire for each person infected. The aim of this questionnaire is to obtain vital information from victims concerning their experiences when touched by E.coli 0157. To date there are probably many databases containing information concerning when and where a person became infected, but the questions 'how' and 'why' remain unanswered. The information you supply, therefore, may help us to find the answers to these questions and possibly reduce the amount of suffering this bacterium can cause. For us to draw as much information as we can we need you to give detailed descriptions of the events surrounding the infection. Please rest assured that all information you provide shall remain strictly confidential. Please return this questionnaire by post to The Heather Preen Trust, 42 Kendal Rise Road, Rednal, Birmingham, B45 9PX. Click on 'Print' at the top of the screen to print out the questionnaire, or click 'File ...', 'Save As ...' to save the questionnaire so that you can complete it off-line. We thank you for your help in this endeavour. A) Personal Details of the infected person Name: Male: Female: Date of Birth: Address: Postcode: Telephone No.:  Ethnicity (please select one): Bangladeshi: Black African: Black Caribbean: Black Other:   Chinese: Indian: Pakistani: White:   Other - Asia: Other: Would you or your family be happy to receive further information from the trust? Yes:     No:   If 'Yes' and the address is different from the above, please supply details: B) Medical History of the infected person Disabilities prior to contamination. None:     Yes - registered:     Yes - not registered:   Were you in good health prior to contamination? Yes:     No:   If 'No' then please provide brief details: C) Occupation of the infected person  Please select one: Skilled Manual: Unskilled Manual: Skilled Non-manual: Unskilled Non-manual:   Managerial: Student/School: Self Employed: Unemployed:   Emergency Services: Prison: Other: D) Investigation of the source of contamination Please supply as many details as possible concerning the investigation conducted by the Public Health Department into the source of contamination. (Please continue on a separate sheet of paper if necessary). Please tell us what your 'gut' belief is of the source of E.coli 0157 bacteria. (Please continue on a separate sheet of paper if necessary). E) Diagnosis Details Date of diagnosis: Age: What were the symptoms? Where was medical attention first sought? Chemist:     Hospital:     G.P.:     Other: Did the G.P. take a stool sample? Yes:     No:   If 'Yes' after how many visits was this? Were any other family members infected? (if 'Yes' fill in a separate form for each). Yes:     No:   How long did it take the authorities to diagnose? What, if any, aspects of the treatment did you consider 'good' or 'bad'? (Please continue on a separate sheet of paper if necessary). Are there any other details surrounding the diagnosis of E.coli 0157 poisoning that you feel you should mention? (Please continue on a separate sheet of paper if necessary). F) Treatment Details How long did the illness last? Was hospital admission required? Yes:     No:   If 'Yes' for how long? Was intensive care treatment required? Yes:     No:   If 'Yes' for how long? If filling in this form for another person, was the infection fatal? Yes:     No:   Was any aftercare needed? (i.e. dialysis, educational support, blood tests, etc.) Yes:     No:   If 'Yes' please provide details of type and duration. (Please continue on a separate sheet of paper if necessary). Are these tests still ongoing? Yes:     No:   If 'Yes' please give details. How much time did you require to take off school / work? Has the infection led to any long term effects? Yes:     No:   If 'Yes' please tell us about these or any other changes in the infected person's life due to the infection, (these effects do not have to be recognised by any professionals, we are only interested in your opinion). (Please continue on a separate sheet of paper if necessary).
Top of Page		Home Page Trust Projects Newsletter Outbreak Reports Research Questionnaire How to contact us