| Gynecological History |
|
17 | Genital infection | 1 = yes, 2 = no |
| Past toxicological history |
|
18 | Alcohol | 1 = yes, 2 = no |
19 | Tabaco | 1 = yes, 2 = no |
| Present pregnancy |
|
20 | Gestational age (day) |
|
21 | Number of fetuses | 1 = one 2 = two 3 = three |
22 | Number of prenatal consultations |
|
23 | ANC done by: | 1 = Gynecologist 2 = General practitioner 3 = Mid-wife 4 = Other |
24 | If CPN done by other precise |
|
25 | HTA during pregnancy (ANC) | 1 = yes, 2 = no |
26 | Gestational diabetes | 1 = yes, 2 = no |
27 | Urinary infection during pregnancy | 1 = yes, 2 = no |
28 | Frequency of sexual intercourse per week |
|
| Medical History |
|
29 | Chronic hypertension | 1 = yes, 2 = no |
30 | Diabetes | 1 = yes, 2 = no |
31 | HIV serology | 1 = Positive 2 = Negative 3 = Not known |
32 | Urinary malformation | 1 = yes, 2 = no |
33 | Kidney failure | 1 = yes, 2 = no |
34 | Cardiac insufficiency | 1 = yes, 2 = no |
35 | Past urinary tract infection | 1 = yes, 2 = no |
Section III: Laboratory Test | ||
36 | Dipstick done | 1 = yes, 2 = no |
37 | Dipstick | 1 = Positive 2 = Negative |
38 | Leucocytiuria | 1 = yes, 2 = no |
39 | If leucocytiuria | 1 = Trace 2 = + 3 = ++ 4 = +++ |
40 | Proteinuria | 1 = Yes, 2 = No |
41 | If proteinuria | 1 = Traces 2 = + 3 = ++ 4 = +++ |