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 ( )