Uganda - Campaign to End Fistula
Uganda - Campaign to End Fistula
Uganda - Campaign to End Fistula
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60OBSTETRIC FISTULA (V.V.F)PATIENT INFORMATIONForm 2Name: ………………………………….Age: ……………………………………Marital status:…………………………..Tribe……………………………………County………………………………….LNMP………………………………….Date of 1 st admission………………………..Date of 1 st repair…..………………………...Living with husband………………………..Separated:…………………………………...Height (cm)…...…………………………….District of origin…………………………….Parity:………..Stature………………………Education standard:NoneP1-3P4-7SecondaryPost secondary1. How long have you been leaking urine/faeces?……………………………………………………………………………………2. How many days after delivery did you start leaking urine/faeces?……………………………………………………………………………………3. How was the baby delivered?a. Vaginal:……………………………………………….……………………..b. C/S:……………………………………………………..……………………c. Assisted vaginal……………………………………….…………………….4. Was the baby born alive?……………………………………………………………………………………5. Where did the delivery take place?a. Hospital/Health unit…………………………………………………………b. Home………………………………………………………………………..c. TBA…………………………………………………………………………d. On the way………………………………………………………………….