N˚Q

QUESTIONS

ANSWER

01

Name of the healthcare facility: 1 = YCH 2 = YUTH

STEPS 1: SOCIODEMOGRAPHIC INFORMATION

02

Gender: 1 = Male; 2 = Female

03

Age (Years):

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

05

Marrital status: 1 = Single 2 = Married 3 = Divorced 4 = Widow 5 = Cohabiting

06

Level of study:1 = Primary 2 = High school 3 = University

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

08

If you are a physician, precise your specialty

1 = General Practitioner 2 = Specialist

09

Including the previous years, what is your average monthly income? ………………….

Tobacco consumption

10

Do you actually smoke products containing tobacco such as cigarette or smoking pipe? if no, jump to 14

1 = yes 2 = no

11

Do you smoke every day? if no precise the frequency

1 = yes 2 = no fréquence: ………….

12

How many cigarettes do you smoke every day? …..........

13

Since when do you smoke? (only one answer)

In years ………………..

In month ………………

In weeks ……………….

Alcohol consumption

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

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

Eating habits

16

In one week, during how many days do you eat fruits?

Number of days ……………….

17

How many fruits do you consume during one of those days

Number of fruits ……………….

18

In one week, during how many days do you eat vegetables?

Number of days ………………

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