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Université de Bamako FACULTE DE MEDECINE, DE PHARMACIE ...

Université de Bamako FACULTE DE MEDECINE, DE PHARMACIE ...

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Q 12 Adressée par /___ /<br />

1 = Mé<strong>de</strong>cin 4 = Venue d’elle-même<br />

2 = Sage femme 5 = Autres<br />

3 = Infirmière<br />

Q 13 Contact à <strong>Bamako</strong> : …………………………………….<br />

Q 14 Parité /___ /<br />

1 = Nullipare 4 = Multipare<br />

2 = Paucipare 5 = Gran<strong>de</strong> multipare<br />

Q 15 Gesticité /___ /<br />

1 = Nulligeste 3 = Multigeste<br />

2 = Paucigeste 4 = Gran<strong>de</strong> multigeste<br />

Q 16 Antécé<strong>de</strong>nts chirurgicaux /___ /<br />

1 = Oui 2 = Non<br />

- Si oui, nature <strong>de</strong> l’intervention /___ /<br />

1 = Myomectomie 2 = Kystectomie<br />

3 = Plastie tubaire 4 = Césarienne<br />

5 = Appendicectomie 5 = Cure <strong>de</strong> prolapsus génital<br />

7 = Salpingectomie 8 = Autres<br />

Q 17 Antécé<strong>de</strong>nts d’avortement spontané /___ /<br />

1 = Oui 2 = Non<br />

Q 18 Antécé<strong>de</strong>nts médicaux /___ /<br />

1 = HTA 2 = Diabète<br />

3 = Drépanocytose 4 = Tuberculose pulmonaire<br />

5 = Autres<br />

Q 19 Antécé<strong>de</strong>nts d’œstrogènothérapie /___ /<br />

1 = Oui 2 = Non

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