You are on page 1of 6

Data collection 1- code of the mother ...............................................

2- age of the mother - below 18 18-20 21-25 26-33 above 33 3- Relegion Hindu Muslim christian sikh parsi any other specify................................................... 4- occupation housewife clerical professional laborer any other specify.............................. 5- monthly family income in Rupees Rs below 5000 5001-10,000 10,001-15,000 15,001- 20,000 20.001 and above 6- type of family Nuclear joint extended 7- Dietary pattern

vegetarian non-vegetarian 8- Height of the mother less then 140 cm 141-150 cm 151-160 cm more than 160 cm

1- what was your age of marriage? - below 18 18-20 21-25 26-33 above 33 2- what was your age at the time of dilevery?-change - below 18 18-21 21-25 26-33 above 33 3- did you register in a hospital when you were pregnant? yes no 4- did you have number of antenatal check up?

yes , ANM staff nurse Dr. speciality obsteritic other no 5- did you take iron folic acid tablets during pregnancy? yes no 6- How many times have you taken TT injection during pregnancy? yes 1 2 3 no 7- had you following any medical disorder during pregnancy? yes, hypertension heart disease DM other No 8- did you have any of the following complication during pregnancy? bleeding infection increasing blood pressure anemia any other No

9- did you have pregnant with the more than one baby like twin? yes no 10- what was interval between previous pregnant and present pregnant? one year tow years not applicable 11- how many weeks had you completed this pregnant? less than 37 weeks more than 37 weeks 12- what was your normal meal pattern? twice a day trice a day four times a day more than four times a day 13- have you increase your dietary intake a day during pregnancy? yes no 14- how many hours have you slept normally during pregnancy? 8 hours sleep at night, and 2 hours at noon 6 hours sleep at night, and 2 hours at noon 6 hours sleep at night without rest at noon 15- did you have any of the following Habits during pregnancy? smoking drinking alcohol tobacco misri none 16- what was your martial status during pregnancy?

married unmarried widow 17- in your family, had any history of low birth weight? yes no 18 how many kilos had you gotten during pregnancy? 8 kg 9-10 kg 11-12kg 13-15 kg 19- did you experience nausea and vomiting during pregnancy? yes no 20 - yes, what did you do to relieve nausea and vomiting? eat dry and starchy food eat small frequent diet avoid skipping meals, fried and fatty food any other specify 21- in your daily activities, which activity had you done during pregnancy? sweeping for long time washing clothes lifting or pulling heavy things standing on foot for long time any other activities 22- did you have any physical exertion during pregnancy? yes no

23- did you have any stress during pregnancy? yes no 24- did you have any abortion before? yes no

You might also like