No | Question | Answer |
| A.DEMOGRAPHIC DATA | |
A1 | Hospital | 1= Kibirizi hospital 2 = CHUB |
A2 | Patient ID | ………………… |
A3 | Gender | 0=Male 1=Female |
A4 | Age (years) |
|
A5 | Occupation | 1 = Farmer 2 = Student 3 = Office agent 4 = Other………………. 5=Unemployed |
A6 | Address of participant | 1. Sector……………… 2. District… 3. Province:………… |
A7 | Marital status | 1 = Single 2 = Married 3 = Widower 4 = Divorced |
A8 | Ubudehe category (Rwandan financial status category) | 1 = Category I (poorest) 2 =Category II 3 = Category III 4 = Category IV (Richest) |
A9 | Health insurance | 1 = Community Based Health Insurance (CBHI) 2 = Rwanda Social Security Board (RSSB) insurance 3 = Others 4 = No insurance |
| B. CLINICAL DATA | |
B1 | Episodes of malaria in the last 5 years | 0 = never 1 = once 2 = two times 3 = three times 4 = four times 5 = five times 6 = above 5 times |
| When was the last episode of malaria |
|
B2 | Stage of splenomegaly (on physical exam) | 1 = Stage II 2 = Stage III 3 = Stage IV 4=Stage V |