No

Questions

Answer codes

I. GENERAL INFORMATION

Q01.

Patient code

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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)

[___]