Report 2011 - Deepalaya

Annex 2- Questionnaire for the case studies
Case studies in Patheni and Gogjaka villages deserved by the mobile clinic September 29 th 2011
Identification :
Name :
Village :
Age :
GPAL :
N. of weeks :
Marital status :
Hb :
Food
Are you vegetarian
How much water do you drink in a day
How do you cook your food
How do you have access to water
Housing :
Do you have access to toilet/latrines
Do you have electricity at home
Infections
Do you/did you have during your pregnancy, symptoms of malaria/parasite infection such as fever, diarrhea,
abdominal pain, worms in your swoon
Have you ever had any pelvic pain or vaginal discharge
Habits :
Do you do physical work
How many hours do you sleep everyday
Do you always wear footwear
What is your educational level
At what age did you get married
Gynecologic history :
Have you ever had any pelvic pain or vaginal discharge
At what age did you have your first menses Have your menstruations always been regular Did you have
spotting Did you have any blood loss during your pregnancy
How many children do you have Did they get full vaccination
Have you ever use any family planning method