S/N˚

Questions

Categories

101

Medical history

No: _________1; Yes: _________2

Specify________________________

102

Surgical history

No: _________1; Yes: _________2

Specify________________________

103

Family history

No: _________1; Yes: _________2

Specify________________________

104

Notion of Medical treatment.

No: _________1; Yes: _________2

Specify________________________

105

Notion of exposure to toxic products

No: _________1; Yes: _________2

Specify________________________

106

Concept of head trauma.

No: _________1; Yes: _________2

107

Neonatal history.

No: _________1; Yes: _________2

Convulsion: ______1; Infection: ______2;

Icterus: ______3 Prematurity: _______4;

Others ___________5

108

EPI vaccination

No: _________1; Yes: _________2

109

DPM

Normal: _________1; Abnormal: ________2