| Number | Questions/Modalities | Answers | |
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| SECTION1: IDENTIFICATION |
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| S1Q1 | Sexe: 1. Masculine 2. Feminine |
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| S1Q2 | Age: |
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| S1Q3 | Contact: |
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| SECTION 2: SOCIO-DÉMOGRAPHIC DATA |
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| S2Q1 | Home: 1. Urban area 2. Rural area |
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| S2Q2 | Region of origin: 1. West, 2. North-west, 3. South-west, 4. Centre, 5. South, 6. East, 7. Littoral, 8. North, 9. Far north, 10. Adamaoua |
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| S2Q3 | Profession: 1. Public/parapublic sector 2. Private sector 3. Informal sector 4. Student 5. Student 6. Unemployed |
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| S2Q4 | Marital status: 1. Single, 2. Married, 3. Engaged, 4. Divorced, 5. Widowed, 6. No partner |
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| S2Q5 | Monthly family income (in FCFA): 1. Less than 50,000, 2. 50,000 to 100,000, 3. 100,000 to 150,000, 4. 150,000 to 200,000, 5. More than 200,000, 6. No fixed income |
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| S2Q6 | Level of study: 1. No schooling, 2. Primary, 4. Secondary, 5. University |
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| S2Q7
| Religion: 1. Animist, 2. Catholic, 3. Protestant, 4. Revival Church, 5. Muslim, 6. Jehovah’s Witnesses 7. Others (specify) |
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| S2Q8 | Do you have children? : 1. No 2. Yes If yes, specify the number |
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| S2Q9 | Children: 1. Non-sickle cell patients (number) 2. Sickle cell patients (number) 3. Not known |
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| S2Q10 | Parents alive: 1. None, 2. Father, 3. Mother, 4. Both |
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| S2Q11 | Sickle cell parents: 1. None, 2. Father, 3. Mother, 4. Both |
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| S2Q12 | Do you have brothers or sisters? : 1. No 2. Yes (specify the number) |
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| S2Q13 | Are there any sickle cell patients among your brothers and sisters? : 1. No 2. Yes (specify number) 3. Not known |
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| S2Q14 | What is your rank among your brothers and sisters? : 1. First, 2. Middle (specify), 3. Last |
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| SECTION 3 : CLINICAL DATA |
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| S3Q1 | How old were you when the disease was diagnosed? |
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| S3Q2 | Under what circumstances was the disease discovered? 1. Systematic screening (systematic screening, family assessment) 2. Anemia, 3. Pain, 4. Infection 5. Other complications | ||
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| S3Q3 | Number of hospitalizations during the last 12 months: |
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| S3Q4 | Frequent reason for hospitalizations (if more than 3): 1. Vaso-occlusive crises, 2. Anemia, 3. Infections |
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| S3Q5 | Number of vaso-occlusive crises during the last 12 months: |
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| S3Q6 | Concept of complications: 1. No 2. Yes If yes, Type of complications: 1. Acute (specify) 2. Chronic (specify) |
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