| S/No. | Question | Response |
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| 1 | What is your sex? | Male | Female |
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| 2 | How old are you? | 2 - 5 | 6 - 8 | 9 - 11 |
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| 3 | How often do you visit the hospital monthly? |
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| 4 | When last did you visit the hospital/receive treatment? | Within the last 3 days | A week ago | A month ago | Others (Please specify) |
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| 5 | What illness did you receive treatment for? | Malaria | Diarrhoea | Typhoid fever | Others (Please specify) |
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| 6 | Do you generally suffer any health challenges? | Yes (Please specify) | No |
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| 7 | Are you currently on any medication? | Yes (Please specify) | No |
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| 8 | Are you currently enrolled in any study? (Formal or Informal) | Yes | No (Give reason) |
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| 9 | If yes, where do you study | At the Camp | Public School | Private School | Missionary School | Other (please specify) |
| 10 | How many times do you eat in a day? | Once a day | Twice a day | Thrice a day | Others (Please specify) |
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| 11 | What type of food is generally served? | Carbohydrates (Please give examples) | Proteins (Please give examples) | Fruits (Please give examples) | Others (Please specify) |
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| 12 | What is the source of your drinking water? | Well | Stream | Tap/pipe borne water | Sachet/Bottled water | Others (Please specify) |
| 13 | What kind of family are you from? | Monogamous | Polygamous | Others (Please specify) |
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| 14 | Where do you defecate? | Pit toilet | Water closet | Open defecation | Others (Please specify) |
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