If yes, please answer the following questions about your obstetrical history

Otherwise, go to IV.

30

Gestity (number of pregnancies)

/_____/_____/

atcd1

31

Number of miscarriages

/_____/_____/

atcd2

32

Parity (number of births)

/_____/_____/

atcd3

33

Number of living children

/_____/_____/

atcd4

34

Have you exclusively breastfed your child (ren)?

0 = No 1 = Yes

atcd5

Social survey

35

Do you drink alcohol daily or often?

0 = No 1 = Yes

es1

36

If so, how many can you estimate in terms of the number of standard glasses per dose?

/____/ standard glasses

es2

37

Do you use tobacco (smoked, chewed, snuffed)?

0 = No 1 = Yes

es3

38

Do you often stay with someone who smokes cigarettes or tobacco (pipe)?

0 = No 1 = Yes

es4

39

Do you use chicha or other narcotics?

0 = No 1 = Yes

es5

Eating habits/behaviours

40

Do you eat fruit and/or vegetables?

0 = No 1 = Yes

ha1

41

If so, how many servings per dose?

/_____/

ha2

42

Specify frequency per week

0 = <3 times/week

1 = ≥3 times/week

ha3

43

How often do you eat fast food?

0 = No 1 = Yes

ha4

44

Do you enjoy consuming too much sugar or sweetened drinks?

0 = No 1 = Yes

ha5

45

Do you enjoy eating foods that are too fatty?

0 = No 1 = Yes

ha6

46

Do you like your food too salty or do you often add salt to the food in your bowl/plate?

0 = No 1 = Yes

ha7

Physical activities

47

Do you do any sport or strenuous physical activity for at least 15 minutes at least three times a week?

0 = No 1 = Yes

prat1

48

Do you walk or do any other moderate physical activity for at least 30 minutes at least three times a week?

0 = No 1 = Yes

prat2

Information on cancer awareness/early detection of breast cancer

49

Have you ever heard of breast cancer?

0 = No 1 = Yes

c1

50

If yes, specify the information channel(s)

1 = Radio

2 = Television

3 = Written diaries

4 = Word of mouth/discussion group

5 = Other…

c2