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 /__/ | Codification /_/_/_/ 1. /_/ 2. /_/_/ 3. /_/ 4. /_/ 5. /_/ 6. /_/_/ 7. /_/ 8. /_/ 9. / _/ 10 10.1. /_/ 10.2. /_/ 10.3. /_/ 10.4. /_/ 10.5. /_/ 11. /_/ 11.1. /_/ 11.2. /_/
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15.1. /_ 15.1.1. /_/ 15.1.2. /_/ 15.1.3. /_/ 15.1.4. /_/ 15.1.5. /_/ 16. /_/_/_/ 17. /_/ 17.1. /_/ 17.2. /_/_/_/_/_/
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