IDENTIFICATION:

1.

File number

2.

Hospital

1. CHRACERH

2. YCH

3.

Initials of first and last name

SOCIODEMOGRAPHIC PROFILE:

4.

Age:

1. ≤15 years

2. 16 - 20 years

3. 21 - 25 years

4. 26 - 30 years

5. 31 - 35 years

6. >35 years

5.

Marital status

1. Single

2. Married

3. Divorced

4. Widow

6.

Religion

1. Catholic 2. Muslim 3. Protestant

4. Pentecostal 5. Jehovah’s Witness

6. Presbyterian

7.

Region of origin

1. Adamawa 2. Central 3. East 4. Far North

5. North 6. Litorral 7. Northwest 8. South

9. Southwest 10. West 11. Foreign

8.

Socio-professional class

1. Private sector employee

2. State employee

3. Unemployed woman

9.

Level of education

1. None

2. Primary

3. Secondary

4. Superior

10.

Residence