No.

Questions

Answers-Codes

I. GENERAL INFORMATION

Q1.

Patient code

[___][___][___][___]

Q2.

Age

[_____]

Q3.

Sex

Male = 1

Female = 2

[___]

Q4.

Level of study

None = 1

Primary = 2

Secondary = 3

Higher = 4

[___]

Q5.

Marital status

Single = 1

Married monogamous = 2

Married polygamous = 3

Married polygamous = 4

Not concerned = 5

[___]

Q6.

If married, age at first marriage

[_____]

Q7.

Number of children

[_____]

Q8.

Nationality

Beninese = 1

Other = 2

[___]

Q9.

If Beninese, specify your origin

Native from the south = 1

Native from the north = 2

[___]

Q10.

Profession

if other, please specify:

Employee/Public Servant = 1

Reseller/Dealer = 2

Worker/Craftsman = 3

Farmer = 4

Pupil/student = 5

None = 6

Other = 7

[___]

Q11.

Place of residence

Cotonou = 1

Outside Cotonou = 2

[___]

II. Lifestyle

Q12.

How often do you drink alcohol?

if other, please specify:

Never = 1

Occasionally = 2

Often = 3

Other = 4

[___]

Q13.

Do you use tobacco

Yes = 1

No = 2

[___]

Q14.

Do you inject drugs?

Yes = 1

No = 2

[___]

Q15.

Do you have multiple sexual partners

Yes = 1

No = 2

[___]