ANTHROPOMETRY AND LOW BIRTH WEIGHT SURVEY SHEET | ||
S1Q01 | Interviewee number | |__||__||__| |
S1Q02 | Date (JJ/MM/AAAA) | |__||__|/|__||__|/|__||__||__||__| |
S1Q03 | Maternal (in years) | |__||__| |
S1Q04 | Region of origin | |__| (1 = Adamawa, 2 = Centre, 3 = East, 4 = Far north, 5 = Littoral, 6 = North, 7 = North-west, 8 = West, 9 = South, 10 = South-west) |
S1Q05 | Religion | |__| (1 = Christian, 2 = Islam, 3 = Others ) |
S1Q06 | Place of residence | |____________________________________| |
S1Q07 | Marital status | |__| (1 = Single, 2 = Married, 3 = Divorced, 4 = Widow) |
SECTION 2: SOCIO-ECONOMIC DATA | ||
S2Q01 | Level of study of father | |__| (1 = None, 2 = Primary, 3 = Secondary, 4 = Superior) |
S2Q02 | Level of study of mother | |__| (1 = None, 2 = Primary, 3 = Secondary, 4 = Superior) |
S2Q03 | Profession of father | |__| (1 = None, 2 = pupil, 3 = student, 4 = worker) |
S2Q04 | Profession of mother | |__| (1 = None, 2 = pupil, 3 = student, 4 = worker) |
SECTION 3: PAST HISTORY | ||
S3Q01 | Gravidity | |____________________________________| |
S3Q02 | Parity | |____________________________________| |
S3Q03 | Term pregnancy | |____________________________________| |
S3Q04 | Miscarriage | |__| (1 = Spontaneous, 2 = Provocked) |
S3Q05 | Intra-uterine death (If no go to S3Q06) | |__| (1 = yes, 2 = No) |
S3Q05A | Nomber |
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S3Q06 | Live children | |__||__| |
S3Q07 | Birth weight of children (in kg) | |
S3Q07A | Weight of first child | |__||__|,|__||__||__| |
S3Q07B | Weight of second child | |__||__|,|__||__||__| |
S3Q07C | Weight of third child | |__||__|,|__||__||__| |
S3Q07D | Weight of fourth child | |__||__|,|__||__||__| |
S3Q07E | Weight of fifth child | |__||__|,|__||__||__| |
S3Q07F | Weight of sixth child | |__||__|,|__||__||__| |
S3Q08 | Sex of children (Only for the sexes, 1 = Male, 2 = Female) | |
S3Q08A | Sex of first child | |__| |
S3Q08B | Sex of second child | |__| |
S3Q08C | Sex of third child | |__| |
S3Q08D | Sex of fourth child | |__| |