Identification number /__/__/__/

1. Sex: 1 male /__/ 0 Female /__/

2. Age: /__/__/ years

3. Religion: 1 Christian /_/ 2 Muslim /_/ 3 Animist /_/ 4 others: ___________________

4. Do you know cirrhosis? 1 yes /__/ 0 no /__/

5. Do you know someone who suffered from cirrhosis? 1 yes /__/ 2 no /__/

6. If yes, for you is this disease: 1 not serious /__/ 2 serious /__/ 3 pas de réponse /__/

7. What do you think of the origin of cirrhosis: 1. Natural /__/ 2 supernatural /__/

8. If the origine is supernatural, do you think it is: 1 wichcraft /__/ 2 spell /__/ 3 no answer /__/ 4 others: ________________

9. What do you think of his prognosis? 1 evolution towards healing /__/ 2 evolution to death /_/ 3 no answer /__/

10. What signs you have presented?

10.1. Abdominal bloating: 1 yes /__/ 0 no /__/

10.2. Abdominal pain: 1 yes /__ / 0 no /__/

10.3. Edea of lower limbs: 1 yes /__/ 0 no /__/

10.4. jaundice: 1 yes /__/ 0 no /__/

10.5. digestive hemorrhage: 1 yes /__/ 0 no /__/

11. Have you viewed from the appearance of the first signs? 1 yes /__/ 0 no /__/

11.1. If yes, who have you consulted? 1 General practitioner /__/ 2 Marabout /__/ 4 Pastor ou Priest /__/ 8 Healer /__/

11.2. If no, give the reason for the no-consultation: 1 lack of financial means/__/ 2 no one to go to me /__/ 4 the fear of the disease /__/ 8 others, specify______________________________________________________

12. What was the opinion of the one who consulted to me the first on the cirrhosis? 1 serious illness /__/ 2 curable disease /__/ 3 others, specify ______________________

13. What are the therapeutic means that have been proposed to you? 1 Pray /__/ 2 inguestion of traditional plants /__/ 4 medicine medications /__/ 8 inguestion of the quanaric inck ink /__/ 16 others, specify____________________________________

13.1. If you have consumed traditional plants, what was the route of administration? 1 oral herbal tea /__/ 2 rectal enema /__/ 4 scarification /__/

14. Have you also self-medicated? 1 yes /__/ 0 no /__/

14.1. If yes, drugs were purchased: 1 at the pharmacy /__/ 0 on the street/__/

14.2. If yes, what medication did you take? 1 analgesic /__/ 2 non steroidal anti inflammatory drugs /__/ 4 diuretic /__/ 8 antibiotic /__/ 16 others, specify ___________________________________________________________________

15. What was the evolution of the disease under the different treatments used? 1 stationary /__/ 2 regression of signs /__/ 3 onset of complications /__/

15.1. If complications appear, specify which ones:

15.1.1. Abdominal pain: 1 yes /__/ 0 no /__/

15.1.2. Digestive hemorrhage: 1 yes /__/ 0 no /__/

15.1.3. consciouness: 1 yes /__/ 0 no /__/

15.1.4. Jaundice: 1 yes /__/ 0 no /__/

15.1.5. Ascites increased: 1 yes /__/ 0 no /__/

16. How long after the various treatments and / or failed treatment did you come to the hospital?/__/__/__/ days

17. How did you pay the consultation fees: 1 cash /__/ 2 in kind /__/

17.1. If in kind, specify ____________________________________________

17.2. Can you estimate the amount of what you spent during this treatment (transport, consultation costs, cost of medication, etc.): /_/_/_/_/_/_/ fcfa equivalent in Euro /_/_/_/_/ ?o:p>

18. Why did you come to the hospital? 1 lack of improvement /__/ 2 by parents’ decision /__/4 on advice from the healer/__/ 8 others, specify__________________________________________

19. What is the etiology of cirrhosis: 1 alcohol /__/ 2 hepatitis virus B /__/ 4 hepatitis virus C /__/ 8 hepatitis virus Delta.

20. What is the Child-Pugh score? 1 class A /__/ 2 class B /__/ 3 class C /__/

21. How do you estimate the evolution in hospital? 1 stationary /__/ 2 a good evolution/__/ 3 an aggravation /__/

22. What is the time of hospitalization? /__/__/__/ days

23. How much you could you estimate the cost of hospital care? (transport, consultation costs, hospitalization fees, fresh biodiversity and mophological examination, drug fees): /_/_/_/_/_/_/fcfa ou Euro /_/_/_/_/_/ ?o:p>

24. Parent questionnaire

24.1. Know about the cirrhosis? 1 yes /__/ 0 no /__/

24.2. If yes, is it a disease: 1 treatable /__/ 2 incurable /__/ no answer /__/

24.3. What do you think of his prognosis? 1 evolution towards healing /__/ 2 evolution to death /__/ 3 no answer /__/

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