3.0

History of urinary tract infection during pregnancy:

[1] Yes

[2] No

3.1

If yes, did you take any antibiotic/s

[1] Yes

[2] No

3.2

If yes, what type/s of antibiotic/s did you take?

And for how long?

4.0

Did you have any pregnancy related problem?

[1] Yes

[2] No

4.1

If yes, state the health problem/s:

5.0

HIV status(refer to the ANC booklet for this question)

[1] Seropositive

[2] Seronegative

6.0

History of any drug/s use during pregnancy:

[1] Yes

[2] No

6.1

If yes, specify the drug/s

6.2

Duration: