N˚Q | QUESTIONS | ANSWER |
01 | Name of the healthcare facility: 1 = YCH 2 = YUTH |
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STEPS 1: SOCIODEMOGRAPHIC INFORMATION | ||
02 | Gender: 1 = Male; 2 = Female |
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03 | Age (Years): |
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04 | région of origin: 1 = Centre 2 = West 3 = North-West 4 = South-West 5 = Est 6 = South 7 = Littoral 8 = Adamaoua 9 = North 10 = Far-North |
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05 | Marrital status: 1 = Single 2 = Married 3 = Divorced 4 = Widow 5 = Cohabiting |
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06 | Level of study:1 = Primary 2 = High school 3 = University |
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07 | To Which professional category do you belong? 1 = Physician 2 = Nurse 3 = Nurse assistant 4 = Midwife 5 = Laboratory assistant 6 = Laboratory technician 7 = Other |
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08 | If you are a physician, precise your specialty 1 = General Practitioner 2 = Specialist |
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09 | Including the previous years, what is your average monthly income? …………………. |
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| Tobacco consumption |
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10 | Do you actually smoke products containing tobacco such as cigarette or smoking pipe? if no, jump to 14 1 = yes 2 = no |
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11 | Do you smoke every day? if no precise the frequency 1 = yes 2 = no fréquence: …………. |
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12 | How many cigarettes do you smoke every day? ….......... |
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13 | Since when do you smoke? (only one answer) In years ……………….. In month ……………… In weeks ………………. |
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| Alcohol consumption |
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14 | Have you ever consumed alcohol like beer, wine or whisky during the past 12 months 1 = yes 2 = no if no jump to 16 |
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15 | If yes, at which frequency? 1 = every day 2 = 5 - 6 days a week 3 = 3 - 4 days a week 4 = 1 - 2 days a week 5 = 1 - 3 days a month 6 = less than one time a month |
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| Eating habits |
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16 | In one week, during how many days do you eat fruits? Number of days ………………. |
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17 | How many fruits do you consume during one of those days Number of fruits ………………. |
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18 | In one week, during how many days do you eat vegetables? Number of days ……………… |
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19 | How often do you add salt or salty sauce in your meal before eating it or while you are eating? 1 = always 2 = often 3 = sometimes 4 = rarely 5 = never |
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