| II. OBSTETRIC GYNECOLOGICAL HISTORY | |||
| Q11. | Gesity |
| [___] |
| Q12. | Parity |
| [___] |
| Q13 | Number of living children |
| [___] |
| Q14 | Spontaneous miscarriages | Yes = 1 No = 2 | [___] |
| Q15. | Induced miscarriages | Yes = 1 No = 2 | [___] |
| Q16 | High blood pressure in pregnancy | Yes = 1 No = 2 | [___] |
| Q17 | Threat of premature birth | Yes = 1 No = 2 | [___] |
| Q18 | Ceasarean | Yes = 1 No = 2 | [___] Specify the number… |
| III. MEDICO-SURGICAL HISTORY | |||
| Q19. | High blood pressure | Yes = 1 No = 2 | [___] |
| Q20. | Diabetes | Yes = 1 No = 2 | [___] |
| Q21. | Sickle cell disease | Yes = 1 No = 2 | [___] |
| Q22. | Haemophilia | Yes = 1 No = 2 | [___] |
| Q23. | Other previous liver pathology | Yes = 1 No = 2 | [___] |
| Q24. | Surgery | Yes = 1 No = 2 | [___] Specify type of surgery |
| Q25. | Blood transfusion | Yes = 1 No = 2 | [___] |
|
| Dialysis | Yes = 1 No = 2 | [___] |
| Q26. | Previous liver pathology | Yes = 1 No = 2 | [___] |
| Q27. | Previous HBV serological status of the pregnant woman | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q28 | If HBV positive (If not go to Q30) | Drug treatment = 1 Traditional treatment = 2 No treatment = 3 | [___] |
| Q29 | HBV viral load | Known = 1 Unknown = 2 | [___] Specify the value if known:…… |
| Q29. | Previous HCV serological status of the pregnant woman | Positive = 1 Negative = 2 Unknown = 3 | [___] |
| Q30 | Si VHC positif, Si non passer au Q32 | Drug treatment = 1 Traditional treatment = 2 No treatment = 3 | [___] |