1

IDNO Surname First Name

2

Date of interview

3

Age in years

4

Sex

5

Religion

(Moslem = 1, Christian = 2, Other = 3 and specify No response = 9)

6

Married status (Married = 1, Single = 2, Divorced = 3, Widowed = 4, No response = 9)

7

Occupation

8

Highest level of education (No formal education = 1, Madrassa = 2, Primary = 3, Secondary = 4, Technical = 5, University = 6, No response = 9)

9

Address

Do you live permanently at the above address? (Yes = 1, No = 2, No response = 9)

10

Have you ever smoked tobacco? (Yes = 1, No = 2, Not Applicable = 8, No Response = 9)

If Yes:

Still a smoker = 1, Stopped less than 6 months ago = 2, Stopped less than 1 year ago = 3,Stopped less than 5 years ago = 4, Stopped greater than 5 years ago = 5

How many years have you smoked in total?

How often do you smoke? (Not every day = 1, 1 - 10 times/day = 2, 11 - 20 times/day = 3, Over 20/day = 4)

Do you smoke: (Cigarette = 1, Pipe = 2, Snuff = 3, Other = 4)

11

Receiving treatment for hypertension? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

If yes, name/dosage

12

Receiving other medicatios? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

If yes, name/dosage

13

Has the doctor ever diagnosed 13a. = Hypertension, 13b. = Obesity, 13c. = Diabetes, 13d. = Heart attack, 13e. = Stroke

Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

14

Family history of 14a. = Hypertension, 14b. = Obesity, 14c. = Diabetes, 14d. = Heart attack, 14e. = Stroke

Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

15

Do you have excessive thirst? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

Do you produce a lot of urine? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response

16

Have you ever experienced severe pain across the front of your chest lasting > ½ hour? Yes = 1, No = 2, Don’t Know = 3, 8 = Not applicable, 9 = No Response