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Service Provision Assessment

[YEAR]

Exit Interview for STI Patients

IDENTIFICATION

Name of the facility_____________________________

Facility location________________________________

Code of the facility

Type of facility * : (1 =Hospital; 2 = Health Centre; 3 = Dispensary;

4 = Maternity and/or Nursing Home; 5 = Clinic)

Type

Client assessment number:

Sex of client (1 = female; 2 = male)

Interview language * :

1 = _______________; 2 = ______________ ; 3 = _________________; ...

10 = _________________

Sex

Date

Day

Month

Year. . . . . . . . . . . . . .

Name of the interviewer_______________________________

Interviewer Code . . . . . . . . . . . . . . .

Beginning time

Hour

Minutes

* Country specific categories should be used.

Exit Interview for STI Patients

Hello. In order to improve the services offered by this facility, we would like to know about your experience here. I would like to ask you some questions about the visit you just had and I would appreciate it if you could spend a little time to answer these questions. All the information given to me will be kept strictly confidential. Your participation is voluntary and you may ask to stop the interview at any time. The care you receive at this facility will not be affected by participating in this interview. I will also be asking you some personal questions and you can refuse to answer at any time.

(SUGGESTION TO INSERT QUESTIONS501-514 BEFORE Q100)

No.	QUESTIONS	CODING CLASSIFICATION	GO TO
100	May I continue?	YES 1 NO 2	STOP
Section 1. Information About the Consultation
101	Why did you come to this health facility today? (CIRCLE ALL MENTIONED) PROBE: What were your symptoms that caused you to come?	LOWER ABDOMINAL PAIN A NON-FOUL SMELLING GENITAL DISCHARGE B FOUL SMELLING GENITAL DISCHARGE C BURNING PAIN ON URINATION D REDNESS/INFLAMMATION E SWELLING IN GENITAL AREA F GENITAL SORES/ULCERS G GENITAL WARTS H BLOOD IN URINE I LOSS OF WEIGHT J REFERRED BY OTHER CLINIC K RETURN VISIT L PARTNER TOLD TO COME M PRESENCE OF PUBIC LICE N OTHER______________________________ X DON'T KNOW Z
102	Before coming to this facility, did you go somewhere else for care?	YES 1 NO 2	104
103	Where did you go? (CIRCLE ALL MENTIONED) (SUGGESTION THAT THE PRECODED 'MEDICAL PRIVATE SECTOR' BE COUNTRY SPECIFIC AND BE HIGHLIGHTED AS SUCH.)	PUBLIC SECTOR GOVERNMENT HOSPITAL A GOVERNMENT HEALTH CENTRE B GOVERNMENT DISPENSARY C MEDICAL PRIVATE SECTOR MISSION, CHURCH FACILITY D FPAK HEALTH CENTRE/CLINIC E OTHER NON-GOVERNMENT SERVICE F PRIVATE HOSPITAL OR CLINIC G PRIVATE DOCTOR H HERBALIST I OTHER______________________________ X
104	Did the health worker ask you about why you came to the clinic?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
105	Did the health worker tell you your diagnosis (what is wrong with you)?	YES 1 NO 2	107
106	What did he/she tell you?	STI, NOT SPECIFIED 1 GONORRHEA 2 SYPHILIS 3 CHLAMYDIA 4 TRICHOMONAS 5 PID 6 DISCHARGE 7 ULCER 8 VAGINITIS 9 CERVICITIS 10 HERPES 11 PUBIC LICE 12 HIV/AIDS 13 OTHER_____________________________ 96 DON'T REMEMBER 98
107	Did the health worker ask you about your most recent sexual contacts?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
108	Did the health worker tell you if and when you need to return to the health facility?	YES 1 NO 2
109	Were you prescribed or given any medications to take at home, given an injection, or not given anything? (CIRCLE ALL MENTIONED)	PRESCRIBED A GIVEN MEDICINE B GIVEN AN INJECTION C NOT GIVEN ANYTHING D
110	IF ONLY C OR D CIRCLED IN Q. 110, CIRCLE 'NO', OTHERWISE CIRCLE 'YES'.	YES 1 NO 2	127
111	How many different medications were you given and/or prescribed?	NO. OF MEDICATIONS
Now I would like to ask you about all your medications one at a time.
112	How often are you supposed to take MEDICINE 1 each day? IF POSSIBLE, NOTE NAME OF MEDICINE 1: ___________________________________________________________ a) How many tablets/capsules are you supposed to take each time?	NO. OF TIMES PER DAY NO. OF TABLETS/CAPSULES
113	For how many days are you supposed to take MEDICINE 1?	NO. OF DAYS. . . . . . . . . . . . . . . UNTIL FINISHED 95
114	IS THERE MORE THAN ONE MEDICINE?	YES 1 NO 2	126
115	How often are you supposed to take MEDICINE 2 each day? IF POSSIBLE, NOTE NAME OF MEDICINE 2:: ____________________________________________________________	NO. OF TIMES PER DAY
116	For how many days are you supposed to take MEDICINE 2?	NO. OF DAYS. . . . . . . . . . . . . . . UNTIL FINISHED 95
117	ARE THERE MORE THAN TWO MEDICINES?	YES 1 NO 2	126
118	How often are you supposed to take MEDICINE 3 each day? IF POSSIBLE, NOTE NAME OF MEDICINE 3: ____________________________________________________________	NO. OF TIMES PER DAY
119	For how many days are you supposed to take MEDICINE 3?	NO. OF DAYS. . . . . . . . . . . . . . . UNTIL FINISHED 95
120	ARE THERE MORE THAN THREE MEDICINES?	YES 1 NO 2	126
121	How often are you supposed to take MEDICINE 4 each day? IF POSSIBLE, NOTE NAME OF MEDICINE 4: ____________________________________________________________	NO. OF TIMES PER DAY
122	For how many days are you supposed to take MEDICINE 4?	NO. OF DAYS. . . . . . . . . . . . . . . UNTIL FINISHED 95
123	ARE THERE MORE THAN FOUR MEDICINES?	YES 1 NO 2	126
124	How often are you supposed to take MEDICINE 5 each day? IF POSSIBLE, NOTE NAME OF MEDICINE 5: ____________________________________________________________	NO. OF TIMES PER DAY
125	For how many days are you supposed to take MEDICINE 5?	NO. OF DAYS. . . . . . . . . . . . . . . UNTIL FINISHED 95
126	When are you supposed to stop taking your medications?	COURSE FINISHED 1 WHEN I FEEL BETTER 2 HEALTH WORKER DID NOT TELL ME 3 OTHER______________________________ 6 DON'T KNOW 8
127	Did the health worker tell you it was important to take all the medication?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
128	Did the health worker talk to you about using condoms?	YES 1 NO 2
129	Were you given any condoms?	YES 1 NO 2
130	Did the health worker ask you if you know how to use a condom?	YES 1 NO 2
131	Did the health worker demonstrate how to put on a condom?	YES 1 NO 2
132	Were you given medicines or a prescription for medicines for your sexual partner(s)?	YES 1 NO 2	134
133	Did the health worker talk to you about telling your partner(s) to seek treatment?	YES 1 NO 2
134	Do you have a contact slip for your sexual partner?	YES 1 NO 2
135	Did the health worker talk to you about HIV/AIDS?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
136	Did the health worker talk to you about how to protect yourself from getting another STI or HIV/AIDS?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
	(SUGGESTION THAT INTERVIEWER REMIND RESPONDENTTHAT THE NEXT SET OF QUESTIONS ARE VERY PERSONAL BUT THE INFORMATION WILL BE USEFUL FOR IMPROVING CARE AT THE FACILITY. "Now I would like to ask you some very personal questions regarding examinations that the health worker might have performed during your consultation." (ANOTHER SUGGESTION IS FOR INTERVIEWERS TO SKIP THE MALE QUESTIONS IF RESPONDENT IS FEMALE (i.e. Q141 & Q142)
137	Did the health worker physically examine your genital area?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
138	IS PATIENT MALE OR FEMALE?	MALE 1 FEMALE 2	141
139	When the health worker examined you, did he/she insert a medical instrument into your vagina?	YES 1 NO 2 DON'T KNOW/REMEMBER 8	143 143
140	Did the health worker insert a finger into your anus?	YES 1 NO 2 DON'T KNOW/REMEMBER 8	143
141	Did the provider examine your penis?	YES 1 NO 2 DON'T KNOW/REMEMBER 8
142	MALE PATIENT: Did the health care worker insert a cotton swab in your penis? FEMALE PATIENT: Did the health worker insert a cotton swab into your vagina?	YES 1 NO 2 YES 1 NO 2
143	Did you have blood drawn?	YES 1 NO 2
Section 2. General Knowledge and Behaviour Now I would like to ask you questions about your sexual experience.
201	When was the last time you had sexual intercourse?	DAYS AGO 1 WEEKS AGO 2 MONTHS AGO 3 YEARS AGO 4	220
202	The last time you had sexual intercourse, was a condom used?	YES 1 NO 2	204
203	What was the main reason you used a condom on that occasion?	OWN CONCERN PREVENT STD/HIV 1 OWN CONCERN TO PREVENT PREGNANCY 2 OWN CONCERN TO PREVENT BOTH STD/HIV AND PREGNANCY 3 DID NOT TRUST PARTNERS/FEELS PARTNER HAS OTHER PARTNERS 4 PARTNER INSISTED 5 OTHER________________________________ 6 DON'T KNOW 8
204	What is your relationship to the person with whom you last had sex?	HUSBAND/WIFE 01 BOYFRIEND/GIRLFRIEND/FIANCEE 02 OTHER FRIEND 03 CASUAL ACQUAINTANCE 04 COMMERCIAL SEX CUSTOMER 05 RELATIVE 06 OTHER_______________________________ 96	206
205	For how long have you had a sexual relationship with this person?	DAYS 1 WEEKS 2 MONTHS 3 YEARS 4
206	Have you had sex with anyone else in the last 12 months?	YES 1 NO 2	217
207	The last time you had sexual intercourse with this other person, was a condom used?	YES 1 NO 2	209
208	What was the main reason you used a condom on that occasion?	OWN CONCERN PREVENT STD/HIV 1 OWN CONCERN TO PREVENT PREGNANCY 2 OWN CONCERN TO PREVENT BOTH STD/HIV AND PREGNANCY 3 DID NOT TRUST PARTNERS/FEELS PARTNER HAS OTHER PARTNERS 4 PARTNER INSISTED 5 OTHER______________________________ 6 DON'T KNOW 8
209	What is your relationship to this person?	HUSBAND/WIFE 01 BOYFRIEND/GIRLFRIEDN/FIANCEE 02 OTHER FRIEND 03 CASUAL ACQUAINTANCE 04 COMMERCIAL SEX CUSTOMER 05 RELATIVE 06 OTHER_______________________________ 96	211
210	For how long have you had a sexual relationship with this person?	DAYS 1 WEEKS 2 MONTHS 3 YEARS 4
211	Other than these two persons, have you had sex with anyone else in the last 12 months?	YES 1 NO 2	217
212	The last time you had sexual intercourse with this other person, was a condom used?	YES 1 NO 2	214
213	What was the main reason you used a condom on that occasion?	OWN CONCERN PREVENT STD/HIV 1 OWN CONCERN TO PREVENT PREGNANCY 2 OWN CONCERN TO PREVENT BOTH STD/HIV AND PREGNANCY 3 DID NOT TRUST PARTNERS/FEELS PARTNER HAS OTHER PARTNERS 4 PARTNER INSISTED 5 OTHER______________________________ 6 DON'T KNOW 8
214	What is your relationship to this person?	HUSBAND/WIFE 01 BOYFRIEND/GIRLFRIEND/FIANCEE 02 OTHER FRIEND 03 CASUAL ACQUAINTANCE 04 COMMERCIAL SEX CUSTOMER 05 RELATIVE 06 OTHER_____________________________ 96	216
215	For how long have you had a sexual relationship with this person?	DAYS 1 WEEKS 2 MONTHS 3 YEARS 4
216	Altogether, with how many different people have you had sex in the last 12 months?	NUMBER OF PARTNERS
217	a) Have you ever paid cash for sex? b) Have you ever been paid cash for sex?	YES 1 NO 2 YES 1 NO 2	220
218	MALE PATIENT: How long ago was the last time you paid for sex? FEMALE PATIENT: How long ago was the last time you were paid for sex?	DAYS AGO 1 WEEKS AGO 2 MONTHS AGO 3 YEARS AGO 4
219	The last time that you (were) paid for sex, was a condom used on that occasion?	YES 1 NO 2
220	Do you know of a place where one can get male condoms?	YES 1 NO 2	223
221	Where is that? IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. _______________________________________________ (NAME OF PLACE)	PUBLIC SECTOR GOVERNMENT HOSPITAL 11 GOVT. HEALTH CENTER 12 FAMILY PLANNING CLINIC 13 MOBILE CLINIC 14 FIELD WORKER 15 OTHER PUBLIC _____________________ 16 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC 21 PHARMACY 22 PRIVATE DOCTOR 23 MOBILE CLINIC 24 FIELD WORKER 25 OTHER PRIVATE MEDICAL________________________ 26 OTHER SOURCE SHOP 31 CHURCH 32 FRIENDS/RELATIVES 33 OTHER_____________________________ 96
222	If you wanted to, could you yourself get a condom?	YES 1 NO 2 DON'T KNOW/UNSURE 8
223	Do you know of a place where one can get female condoms?	YES 1 NO 2	226
224	Where is that?¹ IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. _______________________________________________ (NAME OF PLACE)	PUBLIC SECTOR GOVERNMENT HOSPITAL 11 GOVT. HEALTH CENTER 12 FAMILY PLANNING CLINIC 13 MOBILE CLINIC 14 FIELD WORKER 15 OTHER PUBLIC _____________________ 16 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC 21 PHARMACY 22 PRIVATE DOCTOR 23 MOBILE CLINIC 24 FIELD WORKER 25 OTHER PRIVATE MEDICAL________________________ 26 OTHER SOURCE SHOP 31 CHURCH 32 FRIENDS/RELATIVES 33 OTHER____________________________ 96
225	If you wanted to, could you yourself get a female condom?	YES 1 NO 2 DON'T KNOW/UNSURE 8
227	Where would you get Trust condoms? IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. _______________________________________________ (NAME OF PLACE)	PUBLIC SECTOR GOVERNMENT HOSPITAL 11 GOVT. HEALTH CENTER 12 FAMILY PLANNING CLINIC 13 MOBILE CLINIC 14 FIELD WORKER 15 OTHER PUBLIC _____________________ 16 PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC 21 PHARMACY 22 PRIVATE DOCTOR 23 MOBILE CLINIC 24 FIELD WORKER 25 OTHER PRIVATE MEDICAL________________________ 26 OTHER SOURCE SHOP 31 CHURCH 32 FRIENDS/RELATIVES 33 OTHER____________________________ 96
Section 3. Knowledge of AIDS
301	Now I would like to ask you about another illness related to sex. Have you ever heard of an illness called AIDS?	YES 1 NO 2	316
302	Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?	YES 1 NO 2 DON'T KNOW 8	310 310
303	What can a person do? Anything else? RECORD ALL MENTIONED.	ABSTAIN FROM SEX A USE CONDOMS B LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C LIMIT NUMBER OF SEXUAL PARTNERS D AVOID SEX WITH PROSTITUTES E AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F AVOID SEX WITH HOMOSEXUALS G AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H AVOID BLOOD TRANSFUSIONS I AVOID INJECTIONS J AVOID KISSING K AVOID MOSQUITO BITES L SEEK PROTECTION FROM TRADITIONAL HEALER M AVOID SHARING RAZORS, BLADES N OTHER__________________________ W OTHER__________________________ X DON'T KNOW Z
305	In your view, is a person's chance of getting AIDS influenced by the number of partners he or she has?	YES 1 NO 2 DON'T KNOW 8
306	If a person has sex with only one partner, does this person have a greater or a lesser chance of getting AIDS than a person who has sex with many partners?	GREATER CHANCE OF AIDS 1 LESSER CHANCE OF AIDS 2
308	In your view, is a person's chance of getting AIDS affected by using a condom every time he or she has sexual intercourse?	YES 1 NO 2 UNSURE/DON'T KNOW 8	310 310
309	If a person uses a condom every time he or she is engaged in sexual intercourse, does this person have a greater or a lesser chance of getting AIDS than someone who doesn't use a condom?	GREATER CHANCE OF AIDS 1 LESSER CHANCE OF AIDS 2
310	Is it possible for a healthy-looking person to have the AIDS virus?	YES 1 NO 2 DON'T KNOW 8
311	Do you know someone personally who has the virus that causes AIDS or someone who died from AIDS?	YES 1 NO 2
312	Can the virus that causes AIDS be transmitted from a mother to a child?	YES 1 NO 2 DON'T KNOW 8	314 314
313	When can the virus that causes AIDS be transmitted from a mother to a child? Any others times? RECORD ALL RESPONSES	DURING PREGNANCY A AT DELIVERY B DURING BREASTFEEDING C OTHER TIMES. D DON'T KNOW Z
314	Are you currently married or living with a man/woman?	YES 1 NO 2
315	Have you ever talked about ways to prevent getting the virus that causes AIDS with (your wife/husband or the woman/man you are living with)?	YES 1 NO 2
316	Have you ever been tested to see if you have the AIDS virus?	YES 1 NO 2	319x
317	Would you want to be tested for the AIDS virus?	YES 1 NO 2 DON'T KNOW/UNSURE 3
318	Do you know a place where you could go to get an AIDS test?	YES 1 NO 2	320
319 319x	Where can you go for the test? Where did you go for the test? IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. _______________________________________________ (NAME OF PLACE)	PUBLIC SECTOR GOVERNMENT HOSPITAL 11 GOVT. HEALTH CENTER 12 FAMILY PLANNING CLINIC 13 MOBILE CLINIC 14 FIELD WORKER 15 OTHER PUBLIC 16 ________________________________ (SPECIFY) PRIVATE MEDICAL SECTOR PRIVATE HOSPITAL/CLINIC 21 PHARMACY 22 PRIVATE DOCTOR 23 MOBILE CLINIC 24 FIELD WORKER 25 OTHER PRIVATE MEDICAL___________________________ 26 (SPECIFY) OTHER SOURCE SHOP 31 CHURCH 32 FRIENDS/RELATIVES 33 OTHER______________________________ 96 (SPECIFY)
320	(Apart from AIDS), have you heard about (other) infections that can be transmitted through sexual contact? a) If yes, what type of infection have you heard about?	YES 1 NO 2 (NEED TO ADD PRECODED RESPONSES HERE).

No.	QUESTIONS	CODING CLASSIFICATION	GO TO
SECTION 4. PATIENT SATISFACTION
401	Did you have questions to ask the health worker today?	YES 1 NO 2	404
402	Were you able to ask the questions?	YES 1 NO 2

403	Did you feel comfortable to ask questions during your consultation?	YES 1 NO 2
404	Did you understand the things the health worker explained to you during your consultation?	Did not explain anything 1 Understood some 2 Understood all 3 Did not understand anything 4
405	IF 110 IS YES, THEN CIRCLE '1'. OTHERWISE CIRCLE '2'.	YES 1 NO 2	407
406	Dis the health worker explain how to take the medications?	YES 1 NO 2
407	Did the health worker explain when (under what circumstances) you should return to the clinic?	YES 1 NO 2
408	Do you feel the information given to you during your visit today was too little, too much, or just about right? (SUGGESTION THAT THE QUESTION BE CLARIFIED TO INDICATE WHAT THE CLIENT IS SUPPOSED TO REPORT ON. INFORMATION ON WHAT? IS IT STI SPECIFIC INFORMATION, ETC.?)	TOO LITTLE 1 TOO MUCH 2 ABOUT RIGHT 3 DON'T KNOW 8
409	Do you think that you had adequate privacy during your consultation so that others at the facility could not see or hear you?	YES 1 NO 2
410	Do you think that the information you shared about yourself today at the facility will be kept confidential? (SUGGESTION THAT QUESTION BE CLARIFIED TO MEAN INFORMATION PROVIDED TO THE INTERVIEWER. MAY WANT TO BE MORE SPECIFIC, THAT IS INFORMATION PROVIDED DURING THE CONSULTATION.)	YES 1 NO 2
411	During your visit to the clinic, how were you treated by the health worker?	VERY WELL 1 WELL 2 NOT VERY WELL/POORLY 3
412	During your visit to the clinic, how were you treated by staff other than the one you consulted with?	VERY WELL 1 WELL 2 NOT VERY WELL/POORLY 3
415	How long did you wait between the time you first arrived at this clinic and the time you saw a health worker for your consultation?	MINUTES. . . . . . . . . . . . DON'T KNOW 998
416	Do you feel this waiting time is reasonable or too long?	REASONABLE 1 TOO LONG 2 DON'T KNOW 8
417	In which district and village/town do you live? District ______________________________________ Village/town__________________________________	DISTRICT:
418	Is this the closest health facility providing STI treatment to your home?	YES 1 NO 2 DON'T KNOW 8	420 420
No.	QUESTIONS	CODING CLASSIFICATION	GO TO
419	Why did you not go to the closer facility?	INCONVENIENT OPERATING HOURS 01 BAD REPUTATION 02 DOES NOT LIKE THE PERSONNEL 03 NO MEDICATION 04 PREFERS TO REMAIN ANONYMOUS 05 IT IS MORE EXPENSIVE 06 NOT HAVE DESIRED METHOD 07 LESS CONVENIENT LOCATION 08 OTHER___________________________ 96 DON'T KNOW 98
420	How long did it take you to get here?	MINUTES. . . . . . . . . . . . DON'T KNOW 998
421	What was the main type of transportation you used to get here?	CAR/TRUCK 1 BUS/MATATU 2 MOTORCYCLE 3 BICYCLE 4 ANIMAL 5 WALKING 6 OTHER_____________________________ 7
422	Did you pay an amount (sum of money) for services received here today?	YES 1 NO 2 DON'T KNOW 8	424 424
423	Indicate how much: a) Total. b) For the visit. c) For lab tests/medicines.	KENYAN SHILLINGS: (NEED TO HIGHLIGHT THAT CURRENCY SHOULD BE COUNTRY SPECIFIC) TOTAL. . . . . . . . . . . . VISIT. . . . . . . . . . . . . MEDICINES. . . . . . . . . NO COST = 000 DON'T KNOW = 998
424	How much did it cost you to come to this facility today, including transportation and food?	KS. . . . . . . . . . . . . . . . . NO COST 000 DON'T KNOW 998
425	Did you loose wages from work to come here today? (SUGGESTION THAT THE QUESTION BE REPHRASED TO BE CLEARER AND TO INCLUDE NON-WAGE LOSS.)	YES, LOST WAGES 1 NO, NO LOST WAGES 2 LOST TIME FROM WORK, NON WAGE WORK 3
413	If in the future you have similar problems, would you be comfortable coming back to this health facility?	YES 1 NO 2
414	If you could change one thing about the services you received today, what would that be?	COST 1 TREATMENT 2 WAITING TIME 3 GENERAL ATMOSPHERE 4 OTHER_______________________________ 6 DON'T KNOW 8
SECTION 5. PERSONAL CHARACTERISTICS OF PATIENT
501	In what month and year were you born?	MONTH. . . . . . . . . . . . . . . . MONTH NOT KNOWN 98 YEAR. . . . . . . . . . . . . . . . . YEAR NOT KNOWN 98
502	How old were you at your last birthday?	AGE IN YEARS
503	Have you ever attended school?	YES 1 NO 2	506
504	What is the highest level of school that you attended: primary; secondary; or higher?	PRIMARY 2 SECONDARY 3 HIGHER/UNIVERSITY 4
505	What is the highest standard/form/year you completed at that level?	STANDARD/FORM/YEAR
506	What is your current marital status?	MARRIED/MONOGAMOUS 1 MARRIED/POLYGAMOUS 2 LIVING TOGETHER 3 SINGLE, NEVER MARRIED 4 DIVORCED/SEPARATED/WIDOWED 5
507	How many living children do you have?	NUMBER OF CHILDREN. . . . . . NONE 00
508	What is your religion?	CATHOLIC 1 PROTESTANT/OTHER CHRISTIAN 2 MUSLIM 3 TRADITIONAL RELIGION 4 NO RELIGION 5 OTHER___________________________ 6
509	In the household in which you usually live, what is the main source of drinking water for members of your household?	PIPED WATER PIPED INTO RESIDENCY/COMPOUND/ PLOT 11 PUBLIC TAP 12 WELL WATER WELL ON RESIDENCE/PLOT 21 PUBLIC WELL 22 SURFACE WATER RIVER/STREAM 31 POND/LAKE 32 RAINWATER 41 OTHER______________________________ 96
510	What kind of toilet facility does your household have?	FLUSH TOILET OWN FLUSH TOILET 11 SHARED FLUSH TOILET 12 PIT TOILET/LATRINE TRADITIONAL PIT TOILET 21 VENTILATED IMPROVED PIT (VIP) LATRINE 22 NO FACILITY/BUSH/FIELD 31 OTHER______________________________ 96
511	Does your household have: a) electricity? b) a radio? c) a television? d) a telephone? e) a refrigerator?	YES NO ELECTRICITY 1 2 RADIO 1 2 TELEVISION 1 2 TELEPHONE 1 2 REFRIGERATOR 1 2
512	Could you describe the main material of the floor of your home?	NATURAL FLOOR MUD/DUNG/SAND 11 RUDIMENTARY FLOOR WOOD PLANKS 21 FINISHED FLOOR POLISHED WOOD/VINYL/TILES 31 CEMENT 34 OTHER______________________________ 96
513	Could you describe the main material of the roof of your home?	GRASS/THATCH 11 CORRUGATED IRON (MABATI) 21 TILES 31 OTHER______________________________ 96
514	Does any member of your household own: a) a bicycle? b) a motorcycle? c) a car?	YES NO BICYCLE 1 2 MOTORCYCLE 1 2 CAR 1 2
515	MARK THE TIME	HOUR MINUTES
COMMENTS:

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