QUESTIONNAIRE

DATE – CR NUMBER -
MOTHER’S NAME –
AGE -
EDUCATION STATUS –
OCCUPATION –
FATHER’S NAME –
OCCUPATION –
ADDRESS –

BABY’S INFORMATION –
DATE OF BIRTH-
SEX OF BABY –
BIRTH WEIGHT –

MOTHER’S INFORMATION –
OBSTETRIC HISTORY –

MENSTRUAL HISTORY –

USE OF TOBACCO –
 1ST TRIMESTER
 2ND TRIMESTER
 3RD TRIMESTER

USE OF CONTRACEPTIVES –
IF YES, PLEASE SPECIFY - _______________________________________________________

CONSUMPTION OF ALCOHOL-
IF YES, PLEASE SPECIFY ________________________________________________________

TIME OF ANC REGISTERATION –

NUMBER OF VISITS –
TABLETS OF IRON AND CALCIUM –
IF GIVEN, TAKEN OR NOT –

NUMBER OF MEALS - _________ TIMES / DAY

NUMBER OF TIMES CONSUMING TEA- _________ TIMES / DAY
CONSUMPTION OF GREEN LEAFY VEGETABLES - _________ TIMES / WEEK

TYPE OF EXERCISE –
 HEAVY
 MODERATE
 LIGHT
 NONE

BLOOD LOSS –
IF YES, SPECIFY- ______________________________________________________________

HISTORY OF WORM INFESTATION –

HISTORY OF BLOOD TRANSFUSION –

IF GIVEN, SPECIFY WITH CAUSE - ________________________________________________

INVESTIGATIONS –