CHILD FACTORS |
|
1) Date of birth | _ / _/ _ |
2) Age in months | ….……………. |
3) Sex | 1. Male (…….) 2. Female (……) Tick at appropriate box |
4) Religion | 1. Muslim ( ) 2. Christian ( ) Tick at appropriate box |
5) Birth weight of your child | …………. (kgs) |
6) Your child was born Term or Preterm | 1. Term ( ) 2. Preterm( ) Tick at appropriate box |
7) HIV status of your child | 1. Positive (…..) 2. Negative (….) Tick at appropriate box |
8) Type of the feeding | 1. Breastfeed only( ) 2. Mixed feeding ( ) 3. Formula milk only ( ) 4. Cow milk only ( ) 5. If Others specify ( ) |
9) Duration of exclusive breastfeeding | 1. <6 month (……..) 2. 6 month (……..) 3. >6 month (…….) |
10) Is the child suffered from any chronic illness? If the answer is No is question 10, skip question 11 | 1. Yes ( ) 2. No ( ) |
11) If the answer is yes from question 10, which one among this? | 1. Sickle Cell Disease ( ) 2. Heart Disease ( ) 3. If any other specify …………………… |
12) Is your child on any chronic medication (s)? If the answer is No in question 12, skip question 13 | 1. Yes ( ) 2. No ( ) |
13) If the answer is yes from question 12, which one among this? | 1. Antiepileptic (……) 2. AntiTB (……..) 3. ARV (……..) 4. Specify if any other ……………….. |
14) Milestone | 1. Up-to-date milestones ( ) 2. Delayed milestones ( ) |