ANTHROPOMETRY AND LOW BIRTH WEIGHT SURVEY SHEET

S1Q01

Interviewee number

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S1Q02

Date (JJ/MM/AAAA)

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S1Q03

Maternal (in years)

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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

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

|__|