| No | Question title | Answer options | Code |
| SOCIO-DEMOGRAPHIC DATA | |||
| Q1 | Age (in years) |
| _ _ _ |
| Q2 | Place of origin | 1 = DUH-B/A; 2 = SJZHB; 3 = ATH of Parakou; 4 = EZHB; 5 = SSZHN; 6 = SMZHP; | _ _ _ |
| Q3 | Profession | 1 = Homemaker; 2 = Civil servant; 3 = Learner (student); 4 = Cultivator; 5 = Artisan; 6 = Trader/Seller; 7- Other (specify) | _ _ _ |
| Q4 | Educational level | 1 = None; 2 = Literacy; 3 = Primary; 4 = Secondary; 5 = University | _ _ _ |
| Q5 | Monthly income (FCFA) | 1: < 40,000; 2: [40,000 - 80,000]; 3: [80,000 - 120,000]; 4: [120,000 - 160,000]; 5: [160,000 - 200,000]; 6: >200,000 | _ _ _ |
| Q6 | Marital status | 1 = Single; 2 = Married; 3 = Divorced; 4 = Widowed; 5 = Common-law union | _ _ _ |
| Q7 | Type of household | 1 = Monogamous; 2 = Polygamous | _ _ _ |
| Q8 | Ethnicity | 1 = Bariba; 2 = Dendi; 3 = Fulani; 4 = Fon and related; 5 = Otamari and related; 6 = Yoruba and related; 7 = Others (specify) | _ _ _ |
| Q9 | Religion | 1 = Christian; 2 = Islam; 3 = Endogenous religions; 4 = No religion; 5- Others (specify) | _ _ _ |
| Q10 | Do you consume? |
|
|
| Q10-1 | Tobacco in any form? | 1- Yes; 2- No | _ _ _ |
| Q10-2 | Alcohol? | 1- Yes; 2- No | _ _ _ |
| CLINICAL DATA | |||
| Q11 | Mode of admission | 1- Emergency; 2- Voluntary | _ _ _ |
| Q12 | Reason for consultation |
|
|
| Q12-1 | Desire for maternity | 3- Yes; 4- No | _ _ _ |
| Q12-2 | Pelvic pain | 3- Yes; 4- No | _ _ _ |
| Q12-3 | Dysmenorrhea | 1- Yes; 2- No | _ _ _ |
| Q12-4 | High genital bleeding | 1- Menorrhagia; 2- Metrorrhagia; 3- Menometrorrhagia | _ _ _ |
| Q12-5 | Others (specify) |
| _ _ _ |
| Q13 | Previous Treatments |
|
|
| Q13-1 | Hormonal treatment | 1- Yes; 2- No | _ _ _ |
| Q13-1-1 | If yes, specify |
| _ _ _ |
| Q13-2 | Non-hormonal treatment | 1- Yes; 2- No | _ _ _ |
| Q13-2-1 | If yes, specify |
| _ _ _ |
| PERSONAL HISTORY | |||
| Q14 | Medical History |
|
|
| Q14-1 | Hypertension | 1- Yes; 2- No | _ _ _ |
| Q14-2 | Diabetes | 1- Yes; 2- No | _ _ _ |
| Q14-3 | Coagulation disorders | 1- Yes; 2- No | _ _ _ |
| Q14-4 | Hemoglobinopathy | 1- Yes; 2- No | _ _ _ |
| Q14-5 | Others (specify) |
| _ _ _ |
| Q15 | Surgical History |
|
|
| Q15-1 | Cesarean section | 1- Yes; 2- No | _ _ _ |
| Q15-1-1 | If yes, indication? |
| _ _ _ |
| Q15-2 | Laparotomy | 1- Yes; 2- No | _ _ _ |
| Q15-2-1 | If yes, indication? |
| _ _ _ |
| Q15-3 | Others (specify) |
| _ _ _ |
| Q16 | Family History |
|
|
| Q16-1 | Family history of fibroids | 1- Yes; 2- No | _ _ _ |
| Q16-1-1 | If yes, receive treatment. |
| _ _ _ |
| Q16-2 | Others (specify) |
| _ _ _ |
| Q17 | Obstetric History |
|
|
| Q17-1 | Gesture | 1- Nulligesture 2- Primigesture 3- Paucigesture 4- multigesture 5-great multigesture | _ _ _ |
| Q17-2 | Parity | 1- Nulliparous; 2- Primiparous; 3- Pauciparous; 4- Multiparous; 5- large multiparous | _ _ _ |
| Q17-3 | Number of living children |
| _ _ _ |
| Q17-4 | Miscarriage | 1- Yes; 2- No | _ _ _ |
| Q17-4-1 | If miscarriage, specify the number of times. |
| _ _ _ |
| Q17-5 | Premature birth | 1- Small premature [34 weeks, 37 weeks[; 2- Medium premature [32 weeks, 34 weeks[; 3- Large premature [28 weeks, 32 weeks[; 4- Very large premature [22 weeks, 28 weeks[ | _ _ _ |
| Q17-5-1 | If premature birth, specify the number of times. |
| _ _ _ |
| Q17-6 | Stillborn | 1- Yes; 2- No | _ _ _ |
| Q17-6-1 | If stillborn, specify the number of times. |
| _ _ |
| Q17-7 | Number of deceased children |
| _ _ _ |
| Q18 | Gynecological History |
|
|
| Q18-1 | Menstrual cycle | 1- Regular; 2- Irregular | _ _ _ |
| Q18-2 | Adoption of a contraceptive method | 1- Yes; 2- No | _ _ _ |
| Q18-2-1 | If yes, specify |
| _ _ _ |
| Q18-3 | Others (specify) |
| _ _ _ |
| PHYSICAL EXAMINATION ON ADMISSION | |||
| Q19 | General condition assessment |
|
|
| Q19-1 | General condition | 1- Satisfactory; 2- Not very satisfactory; 3- Altered | _ _ _ |
| Q19-2 | Pallor | 1- Yes; 2- No | _ _ _ |
| Q19-3 | Temperature | 1- Normal; 2- Hypothermia; 3- Hyperthermia | _ _ _ |
| Q19-4 | Blood pressure | 1- Normal; 2- Hypotension; 3- Hypertension | _ _ _ |
| Q19-5 | Weight (in kg) |
| _ _ _ |
| Q19-6 | Height (in m) |
| _ _ _ |
| Q19-7 | Body Mass Index (BMI) (in kg/m2) |
| _ _ _ |
| Q20 | Obstetrical examination |
|
|
| Q20-1 | Uterine height (in centimeters) |
| _ _ _ |
| Q20-2 | Uterine contour | 1- Smooth; 2- Regular; 3- Irregular; 4- Bumpy; 5- Others (specify) | _ _ _ |
| Q20-3 | Sensitivity | 1- Painful; 2- Painless | _ _ _ |
| Q20-4 | Mobility | 1- Fixed; 2- Mobile | _ _ _ |
| Q20-5 | Consistency | 1- Hard; 2- Stony; 3- Firm; 4- Elastic | _ _ _ |
| Q20-6 | Others (specify) |
| _ _ _ |
| PARACLINICAL EXAMINATIONS | |||
| Q21 | Ultrasound |
|
|
| Q21-1 | Fibroids | 1- Yes; 2- No | _ _ _ |
| Q21-1-1 | If yes, single or multiple |
| _ _ _ |
| Q21-1-2 | Size of fibroids (in millimeters) | 1- [0; 2]; 2- [3; 5]; 3- ≥6 | _ _ _ |
| Q21-1-3 | Location: FIGO Classification (Stages) | 1- [0]; 2- [1]; 3- [2]; 4- [3]; 5- [4]; 6- [5]; 7- [6]; 8- [7]; 9- [8]; 10- 2 - 5 | _ _ _ |
| Q21-2 | Ovary status: Cysts? | 1- Yes; 2- No | _ _ _ |
| Q21-4 | Tubes visualized? | 1- Yes; 2- No | _ _ _ |
| Q21-4-1 | If yes, hydrosalpinx? | 1- Yes; 2- No | _ _ _ |
| Q21-4-2 | Hematosalpinx? | 1- Yes; 2- No | _ _ _ |
| Q22 | CBC or Hemoglobin level (g/dl) |
| _ _ _ |
| Q23 | Outcome |
|
|
| Q23-1 | Favorable outcome | 1- Yes; 2- No | _ _ _ |
| Q23-1-1 | If no, complications? | 1- Menorrhagia; 2- Pelvic pain; 3- Anemia; 4- Infertility; 5- Others (specify) | _ _ _ |
| Q23-1-2 | Recurrences | 1- Yes; 2- No | _ _ _ |