Table 5

Name and Surname of the head of the family

Complete address and telephone ...

Each resident in the apartment should complete a separate questionnaire

Resident 1, Resident 2 etc.

Family relation (spouse, son etc)...

Age ...

Sex ...

   1. Have you been present in the apartment during the 10, 11 or 12 of the current month? Yes/No

   2. Did you drink tap water during those days? Yes/No

   3. How many glasses of water do you usually drink per day? Number...

   4. During those days did you use tap water to prepare food? Yes/No

   5. During those days did you bathe or shower at home? Yes/No

   6. During those days where you exposed to gases, vapors or fumes at home? Yes/No

   7. Between the 10 and the 14th of this month did you suffer from:

a. Abdominal pain

b. Diarrhea

c. Nausea

d. Vomit

e. Fever

f. A feeling of bad taste in the mouth

g. Irritation in the pharynx

h. Skin eruption

i. Skin irritation

j. Nasal Irritation

k. Nasal secretion

l. Eye irritation

m. Perception of bad odors

   8. Did you consult a medical doctor? Yes/No

   9. If you had any symptoms how long did they last?

   10. Do you have any allergies Yes/No

   11. Any other observations? Specify