No | Questions | Answer codes | |
| I. GENERAL INFORMATION | ||
Q01. | Patient code | [___][___][___][___] | |
Q02. | Age | [_____] |
|
Q03. | Religion | Christian = 1 Muslim = 2 Animist = 3 Other = 4 None = 5 |
[___] |
Q04. | Level of study | None = 1 Primary = 2 Secondary = 3 University = 4 |
[___] |
Q05. | Marital status | Single = 1 Married monogamous = 2 Married polygamous = 3 Divorced/widowed = 4 Not concerned = 5 |
[___] |
Q06. | Nationality | Beninese = 1 Other = 2 | [___] |
Q07. | If beninese, specify ethnicity | ||
Q08. | Municipality of origin | Lokossa = 1; Athieme = 2 Come = 3 Grand-Popo = 4 Houeyogbe = 5 Bopa = 6 Other = 7 (specify) |
|
Q09. | Profession | Teacher = 1 Reseller/merchant = 2 Worker/artisan = 3 Farmer = 4 Student = 5 None = 6 Other = 7(to be specified) | [___] |
Q10. | Place of residence | Lokossa = 1 Athieme = 2 Come = 3 Grand-Popo = 4 Houeyogbe = 5 Bopa = 6 Other = 7(to be specified) | [___] |