| N˚ | Question | Code | Answer | |
| SECTION 1: Identification and sociodemographic parameters | ||||
| Q1 | Place of recruitment (SERVICE) | 1 = CHIPED 2 = VISCERAL 3 = BU 4 = FONTAN |
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| Q2 | Age\SEX |
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| Q3 | Nationality | 1 = Cameroonian 2 = Other |
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| Q4 | If cameroonian what region | 1 = Adamaoua 2 = Center 3 = East 4 = Extreme North 5 = Littoral 6 = North 7 = Northwest 8 = West 9 = South 10 = South west |
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| Q5 | Marital status | 1 = Married 2 = Single 3 = Divorved 4 = Cohabitation 5 = Widow |
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| Q6 | Level of education | 1 = No level 2 = Primary 3 = Secondary 4 = University |
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| Q7 | Profession | 1 = Student 2 = Housewife 3 = Liberal 4 = Non liberal 5 = Other |
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| If other, specify |
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| Q8 | Religion | 1 = Catholic 2 = Protestant 3 = Pentecostant 4 = Muslim 5 = other |
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| If other, specify |
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| SECTION 2: PAST HISTORY | ||||
| Past medical history | ||||
| Q27 | Diabetes | 1 = Yes 2 = No |
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| Q28 | HTN | 1 = Yes 2 = No |
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| Q29 | Tuberclosis | 1 = Yes 2 = No |
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| Q30 | Blunt Abdominal trauma |
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| Q31 | Pancreatitis |
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| Q32 | Tubo-ovarian abcess |
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| Q33 | Others, if yes precise |
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| Past Surgical History | ||||
| Q34 | Have you ever been operated | 1 = Yes 2 = No |
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| Toxicology | ||||
| Q35 | Alcohol | 1 = Yes 2 = No |
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| Q35a | If yes alcohol calculate Index |
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| Q36 | Smoking | 1 = Yes 2 = No |
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| Q36a | If yes calculate pack years |
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| Mode of life | ||||
| Q37
Q37a Q37b Q37c | Physical activity. If yes which Jogging Walking Running | 1 = Yes 2 = No
1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No |
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| Q38 | Consumption of vegetables | 1 = Yes 2 = No |
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| Q39 | Consumption of Fruits | 1 = Yes 2 = No |
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| Q40 | Excessive Consumption of sugar | 1 = Yes 2 = No |
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| Family history | ||||
| Q41 | Are they diabetics in 1st Degree family | 1 = Yes 2 = No |
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| Q42 | If yes Type 1 | 1 = Yes 2 = No |
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| Q43 | Type 2 | 1 = Yes 2 = No |
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| Q44a | MALIGNANCIES | 1 = Yes 2 = No |
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| Q45b | If yes specify |
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| Section 4: Functional signs | ||||
| Q46 | VOMITING | 1 = Yes 2 = No |
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| Q47 | CONSTIPATION | 1 = Yes 2 = No |
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| Q48 | ABDOMINAL PAIN | 1 = Yes 2 = No |
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| Section 5: HISTORY OF COMPLAINTS | |||
| Q49 | Duration of symptoms | State | ||
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| Section 6: Physical examination | |||
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| 1) BP: 2) pulse: 3) respiratory rate 4) temperature 5) Anesthesiste score |
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| Q50 | Diagnosis at entry |
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| Q51 | Workup done | 1 = ultrasound 2 = CT scan 3 = Plain abdominal xray |
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| Q52 | RESULTS OF WORKUPS |
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| Q53a | PER OPERATORY DIAGNOSIS |
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| Q53b | DISCOVERIES |
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| Q53c | GESTURES |
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| Q54 | COMPLICATIONS | 1 = YES 2 = NO |
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| IF YES STATE THE COMPLICATION WITH RESPECT TO TIME OF ONSET | |||
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| 1 = IMMEDIATE (0 - 24 HRS) |
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| 2 = EARLY (DAY2 - DAY5) |
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| 3 = LATE (>DAY5) |
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