SN contact phone Ward no/Tole Name A.8.

4 Age
1 9822317076 9 kashi maya bk 35
2 9 krishna bk 47
3 rashila bk 17
4 ashish bk 12
5 imeliya bk 1o months
6 9812765317 9 kamal bk 33
7 sarada bk 31
8 babu bk 12
9 sima bk 13
10 9819233097 9 damar kumari karki 29
11 upendra karki 31
12 vumika karki 9
13 ritesh karki 4
14 9849147149 9 bhadra bahadur bk 54
15 maiya bk 51
16 dependra bk 26
17 puja bk 25
18 sajan bk 6
19 9816709303 9 naumaya bk 32
20 amar bk 42
21 anisha bk 17
22 abisha bk 16
23 aakash bk 11
24 ashika bk 10
25 aayush bk 2
26 9 dhan bahadur bk 41
27 kamala bk 43
28 bhim bk 2
29 bhisan bk 16
30 985606174 9 bandana bk 18
31 rabil bk 29
32 santosh bk 31
33 yosheph bk 4
34 9816788620 9 bishnu kumar rai 53
35 parbat kumar rai 30
36 bishnu maya rai 55
37 sumi rai 23
38 santa rai 25
39 suna bung rai 17 months
40 9824340818 9 goma lamichhane 50
41 subina lamichhane 23
42 mina lamichhane 25
43 rojnil lamichhane 6
44 rojjwal lamichhane 4
45 9812567348 9 bimal bk 47
46 santosh bk 23
47 khem kumar bk 20
48 laxmi bk 44
49 bimala bk 18
50 puja bk 7
51 9 Panchimaya bk 72
52 9800921451 9 saili maya rai 75
53 naumati rai 45
54 akriti rai 25
55 krishna rai 30
56 9811944515 9 Ram kumari rai 83
57 suvamati rai 47
58 santa bahadur rai 45
59 prakash rai 22
60 9840043579 9 sharda rai 30
61 manju rai 18
62 anju rai 14
63 anita rai 12
64 anisha rai 10
65 kewal rai 7
66 9819984108 9 mandira thapa 42
67 usha thapa 26
68 bhim bahadur thapa 50
69 ashish thapa 28
70 aayan thapa 6
71 9822315267 9 harka maya karki 63
72 demraj thapa 27
73 9805998657 9 tulsi thapa 37
74 bir bahadur thapa 67
75 sachin thapa 16
76 samyog thapa 10
77 geeta thapa 38
78 jagmaya thapa 63
79 sabina thapa 14
80 9821792306 9 avi naryan newar 37
81 arjun kumar newar 15
82 bhim narayan newar 10
83 mina newar 37
84 kabita newar 17
85 9821794324 9 baburaj thapa 35
86 subit thapa 14
87 sushant thapa 9
88 bimal thapa 26
89 9815751236 9 sita shrestha 25
90 chandra maya shrestha 60
91 jamuna shrestha 7
92 nagendra shrestha 60
93 nirmal shrestha 4
 94 deep bahadur shrestha 29
96 9819902781 9 khagendra thapa 30
97 sop bahadur thapa 64
98 nirjal thapa 4
99 manmaya thapa 60
100 hemkala thapa 21
101 pabitra thapa 86
102 9807391451 3 rekh gurung 36
103 simon gurung 12
104 tilak gurung 40
105 nayan gurung 14
106 9803344172 3 sabitra sunar 35
107 bitisha sunar 15
108 dibya sunar 2
109 nishan sunar 6
110 bilson sunar 20
111 bijay sunar 42
112 9814757568 3 amrit thapa 44
113 roshan thapa 16
114 nishan thapa 12
115 geeta thapa 34
116 sital thapa 17
117 9813196519 3 ratna bahadur thapa 44
118 roshan thapa 19
119 sanjay thapa 13
120 sagun thapa 9
121 dema thapa 34
122 9827733271 3 tulasi thami 29
123 saroj thami 26
124 vision thami 4
A. 8.5 Sex A.9. Marital Status A.10 Religion A.11 Ethnicity A.12. Literacy A.13. Highest Edu level
2 2
1 2
2 1
1 1
2 5
1 2
2 2
1 1
2 1
2 2
1 2
2 1
1 1
1 2
2 2
1 2
2 2
1 5
2 2
1 2
2 1
2 1
1 1
2 1
1 5
1 2
2 2
1 1
1 1
2 1
2 2
1 2
1 5
1 2
1 2
2 2
2 2
2 1
2 5
2 3
2 2
2 2
2 5
1 5
1 2
1 2
5 3
1 3
1 1
1 3
1 3
1 3
5 3
2 2
1 3
1 3
2 _
1
3 9
3 4
4
3 2
3 8
3 6
3 6
3 9
3 5
3 1
4
1
1
3 1
3 1
3 2
1
3 3
3 10
3 8
3 5
3 3
4
1
1
3 10
3 8
3 9
3 9
3 12
4
3 8
3 12
1
3 12
3 12
4
1
3 10
3 10
3 1
4
3 4
3 9
1 1 3 9
2 2 3 2
2 1 3 10
2 1 3 2
2 3 1 3 1
2 3 1 2 1
2 1 3 2
2 2 3 10
1 2 3 10
2 3 1 2 1
2 2 1
1 2 3 5
1 1 3 12
2 2 1 2 1
1 1 3 9
2 1 3 8
2 1 3 4
2 1 3 4
1 1 3 1
2 2 1 1 3 4
2 2 3 12
1 2 3 10
1 2 3 12
1 5 4
2 2 1 2 1
1 1 3 10
1 2 1 1 3 10
1 2 1
1 1 3 10
1 1 3 4
2 2 3 10
2 2 1
2 1 3 6
1 2 1 2 3 9
1 1 3 9
1 1 3 4
2 2 1
2 1 3 12
1 2 1 2 1
1 1 3 5
1 1 3 1
2 2 3 7
2 2 1 2 3 9
2 2 1
2 1 3 1
1 2 2
1 1 3 1
1 2 3 10
1 2 1 1 3 11
1 2 1
1 5 4
2 2 1
2 2 3 10
2 3 1
2 2 3 2 3 10
2 1 3 6
1 2 3 10
1 1 3 7
2 2 1 3 3 8
2 1 3 8
2 1 4
1 1 3 1
1 1 3 11
1 2 3 9
1 2 1 1 1
1 1 3 9
1 1 3 7
2 2 1
2 1 3 12
1 2 1 1 3 9
1 1 3 10
1 1 3 6
1 1 3 4
2 2 2
2 2 1 2 3 12
1 2 2 3 10
1 1 2 3
 A.14 Type of School A.15 Occupaion A.16 Illness within 1 year A.17 Illness Duration(Weeks)
_ 8_ _
4
1 7 1 1
2 7
12
1 1
1 1
1 7
1 7
1 1
1 2
2 12
12 1 1
2
8
1 5
1 8
2 7 1 1
2
1 6
1 7
1 7
1 7
1 7
12
2
1
1 3
1 3
1 7 2
1 1
1 3
5 12
1 6 2
1 5
3 8
1 8
1 3
12

3 8 2
1 8
1 8
2 12
1 4 2
1 2
1 8
1 8
1 8
1 7
3 8
3 8
1 1
1 1
1 1
3 8
3 1
1 1
2 6
1 1 1
3 7
1 7
1 7
1 7 1 2
1 7
1 6
2 8
1 6
2 4
3 12
1 2
1 3
1 1
8 1 1
1 7
1 7
1 8
8
1 7
1 1 2
1 7
1 7
1
1 7
1 2
2 7
2 12
1 1
1 8 2
8
1 7
1
1 12
1 2
1 1 2
3 1
3 12
3 1
1 8
3 1
1 1 2
1 7
1 1
1 7
1 8 2
1 7
3 12
1 7
2 3
1 8
1 2
1 7
1 7
1
1 7
1 1 2
1 8
1 7
1 7
1
1 1 2
1 4
2 12
A.1 Total Family Members A.2 Land Holding(kattha) A.3 Family type A.4 House type
2 1 1 2

2 1 1 2

2 1 1 3

2 1 1 2

3 1 1 1

2 1 2 2

2 1 1 2

3 1 1 2

2 1 2 2

3 1 1 2
1 31-Dec 1 1
2 1 2 2

2 1 2 1

3 1 1 1

2 2 3

1 1 2

3 1 2 2

2 1 1 2

2 1 1 1

3 1 2 3
3 1 2 2

2 1 1 1

3 1 1 2

2 1 1 1

2 1 1 2

2 1 1 2
A.5 Mother tongue A.6 HF Distance A.7 Food Sufficiency A.8.1 Birth(within 1 year)
1 1 1 1

1 1 1 2

1 1 2 2

1 1 1 2

1 1 1 2

1 1 1 2

1 1 3 2

3 1 1 2

1 1 2 2

1 1 2 2
1 1 2
3 1 1 2

1 1 2

1 2 1 2

1 1 2

1 1 3 2

1 1 2 2

1 1 1 2

1 1 2 2

1 1 1 2
1 1 1 2

1 1 2 2

1 1 1 2

1 1 3 2

1 1 2 2

1 1 1 2
A.8.1.1 If yes, Number Sex A.8.2 Death (within 1 year) A.8.2.1 Number of Deaths Sex
1 2 2

1 1 1

2
2

2 2
2

2
A.8.3 Age at death (1) A.8.3 Age at death (2) Cause of death(1) Cause of death(2) Death Certificates

74 TB
B1. Source of drinking water B2. Water source distance B3.1. Process water? B3.2. If yes, How?
3 1 1 2

3 1 1 2

3 1 2

3 1 2

3 1 2

3 1 1 2

3 1 1 2

3 1 1 2

3 1 1 1

3 1 1 1
3 1 2
3 1 2

3 1 1 3

3 2 1 1

3 1 1 2

1 1 2

1 1 2

1 1 2

3 1 1 1

1 2
1 1 1 2

1 1 2

1 1 2

1 1 2

1 1 2

1 1 2
B4. Wash hands with? B5. Bath how often? B6.1 Toilet B6.2 Toilet type B6.3 Toilet Use
2 4 1 2 3

2 4 1 2 3

2 3 1 1 3

2 4 1 2 1

2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 1 1 2 3
2 4 1 2 3
2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 4 1 1 3

2 4 1 2 3

2 4 1 1 3

2 4 1 2 3

2 1 1 2 3

2 4 1 2 3
2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 4 1 2 3

2 4 1 1 3

2 4 1 3 3
B6.4 If no toilet, defecate where? C1.1.1. ANC Visit? C1.1.2. If yes, where?
1 2
C1.1.3. Number of ANC Visits C.1.2.1. Received TD C.1.2.2 If yes, how many Dose Interval
8 1 2 6 months
C.1.3. Taken Iron/Folate C.1.4 Food amount eaten in pregnancy C.1.5 Food avoided in preg
4 1 non veg
 If yes, avoided what? C.1.6 Special food taken in preg If yes, what?
non veg 2
C.1.7 Place of delivery C.1.7.1 If home, who attended C.1.7.2 Sutkeri samagri used?
2 1 1
C.1.7.3 Cut cord with what? C.1.7.4 Stump application C.2.1 FP Methods Spontaneous
nabi cream 3

3, 5

3,7

2,3

1,2,3

3,5

1,3,4
2,3

1,2,3,4,5

1,2,3,6,7

1,2,3,5,6,7

2
1,2,3,5,6,7

2,3,4

2,3,4,5

1,2,3,4,5,6,7

1,2,3,6,7

1,3,4
 C.2.1 FP Methods probed C.2.2. Ever use FP method If yes, which method?
5 1 3

1,2,6,7 1 3

3 2

6,7 2

1,4 1 3

1 1 3

0 0 0

6,7 2

1,4,6,7 2

2,5,6,7 2
 2
2

6,7 1 3

2,3,6,7 2

6,7 2 3

1 3

1 5

1,3,4,5,6,7 1 2
 2

1,5,6,7 2

1,6,7 1 5

1 3

2,5,6,7 1 3
C.2.3. Current FP method use If yes, which method? C.3.1 Child's first feed?
2 1

2
2
2

1 3

2 3

1 2

1 5

2
2

1 5

2
C.3.2 If no colostrum, why? C.3.3 Breastfeed start after birth(hr)
1
C.3.4 Breastfeeding duration(months) C.3.5 Receiving supplementary milk feeds?
10 2
C.3.6. Child started on solid food? If yes, at what month? C.4.1 BCG Rota I Rota II
1 6 1 1 1
Penta I Penta II Penta III fIPV I fIPV II PCV I PCV II PCV III MR I MR II JE TCV
1 1 1 1 1 1 1 1
Source of info Child aged 12-23 months immunized fully or not? D.1.1 Illness type
2 1
D.1.1.2 Treatment Place Outcome D.1.2 Family h/o disease D.1.3Prefer to Treat where?
2 2 6 1
5 1

1
6 1

2
D.1.4 HF Services rating D.1.5 Enrolled in Insurance D.1.6 If yes, Satisfied?
3 2
4 2

3 1 3
4 1 3

4 2
D.2 1 Any injuries(6months) D.2.2 If yes, cause disability? D.2.3 Mechanism of Injury
2
2
D.2.4 Physical nature D.2.5 Place D.2.6 Anyone died? If yes, Age at death
2
D.3.1 Total Family Income/year D.3.2 Percapita Income(Rs/person/year) D.3.3 Povertyline
480000 96000 2

120000 30,000 1

240000 60000 1

360000 32000 1

35000 5000 1

360000 90000 1

600000 150000 2

180000 30000 1

180000 36000 1

180000 30000 1
 1
120000 30000 1

240000 60000 1

120000 20000 1

600000 120000 2

84000 12000 1

120000 24000 1

120000 30000 1

144000 24000 1
180000 30000 1

180000 45000 1

120000 20000 1

180000 36000 1

120000 24000 1

240000 80000 1
E.1.1 Clean teeth E.1.2 clean with what? E.1.3 Toothpaste flourination E.1.4 Brushing time
1 1 1 1

1 1 1 1

1 1 1 1

1 1 1 1

1 1 1 2

1 1 1 2

1 2 2 2

1 1 1 1

1 1 1 2

1 1 1 1
2 6 3 1
2 1 1 1

1 1 1 2

1 1 1 2

1 1 1 1

1 1 1

1 1 1 1

1 1 1 1

1 1 1 2

1 1 2 1
1 1 1 1

1 1 3 1

1 1 1 1

1 1 1 1

1 1 1 1

1 1 1 1
E.1.5 Toothbrush change E.1.6 Oral hygiene aids E2 Ever had dental problem?
3 3 2

2 3 2

3 3 2

2 3 1

1 6 1

1 3 1

2 3 2

2 3 1

1 3 1

2 3 2
 1
3 3 2

2 3 2

3 3 1

3 3 1

3 3 2

1 3 1

2 3 1

1 5 2

1 3 1
2 3 2

2 3 2

1 3 1

2 5 2

2 3 2

2 3 2
E.2.1 Pain in tooth Bleeding gums Swollen gums Missing tooth
2 2 2 2

2 2 2 2

2 2 2 2

2 2 2 2

2 2 2 2

2 2 2 2
1

1
1
Foul breath Malaligned teeth others E.2.2 Consulted_None
2 2

2 2

2 2

1 1

2 2 2 2

2 2 1 2

2 2 1 2
 1

1 1
1
Consulted_Friends/\neighbour Consulted_relative Consulted_Medical practitioner

2 2 2

2 2 2

1 2 2
 1

1
Consulted_Pharmacist/\chemist Consulted_Trained dentist

2 2

2 1

2 2
1

1
Consulted_untrained dental worker Consulted_others E.2.3 Treatment provided

2 2 2

2 2 1

2 2 5
5

5
E.3.1 Common problems of mouth/teeth E.3.2 Factors causing problems

7 2

1 1

1 1

1 1

2 2
 1 2
1 1

1 1

1,3 5

1 1

1 1

1 1

7 1

1 1
 1 1

1 1

2,3 5

1 1

2 2

1 1
 E.4.1 Aware of tobacco substances E.4.2 Source of information E.4.3 Paan E.4.3 Chilim E.4.3 Gutkha
7 1 2 2 2

1,6 1

5 2

5 2

5 2

6 2

6 2

6 2

5,6 2
 6 2
5,6 2

5,6 2

5 2

5 2

6 2

5,6 2

5,6 2

3,7 2
5,6 2

6 2

1 2 2

5,6 2

5,6 2

5,2 2
E.4.3 Hookah E.4.3 Tambakhu E.4.3 Ciggerate E.4.3 Bidi E.4.4 Monthly expense (Rs)
2 2 2 2

1 1
1 1

1 1

1 1

1 1

3 2 40
3 500

1 200

2 2 100

1 1

1 1

1 1
 E.4.5 Benefits of tobacco E.4.6 Long term ill-effects of paan E.4.6 Chilim E.4.6 Gutkha
1 4

1 3

4,8

1
1
1

1
1

1 3

1
E.4.6 Hookah E.4.6 Tambaku E.4.6 Ciggerate E.4.6 Bidi E.4.6.1 If cancers, sites?
6

3 4

3 5

3 5

3 6

3 5

5 5

3 3 4
 3 4
2 2 5

2 2

3 5

1 3

3 5

3 5

3 3 5

3 3 5

3 3 4
3 3

3 5

3 3 4,5

3 3 5

3 2
E.4.7 Immediate ill-effects of paan E.4.7 Chilim E.4.7 Gutkha E.4.7 Hookah E.4.7 Tambaku
2 2 2 2 2

8 8

6
 2

4,5

1
 1

3
E.4.7 Ciggerate E.4.7 Bidi E..4.8 Possible to quit? E.4.9 Support required to quit
2 2 1 2

2 4

2 6

1 1

2 6

2 1

2 1

1 2

6 2 1

6 1 2
6 2 1
2 2 1

2 2 1

1 4

1 2

2 1 4

2 1

6 2 3

4 1 3

1 1 6
 1 2

1 2

1 6

6 1 2

1 2

1 3
E.4.10 Source of embaressment? E.5.11 Should use be allowed among adolescents?
1 2

1 2

2 2

1 2

1 2

1 2

1 2

1 2

2 2

1 2
1 1
2 2

2 1

1 1

2 2

2 2

2 2

2 2

2 2

2 2
2 2

1 2

2 2

1 2

2 2

2 2
E.4.12 Should ads be banned on media? E.4.13 Should prod/sale/consumptn be banned?
1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1
1 1
1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1

1 1
1 1

1 1

1 1

1 1

1 1

1 1
 Sex Marital status Religion Ethinicity/Caste
Male 1 Single 1 Hindu 1 Hill Brahmin/Chhetri 1
Female 2 Married 2 Kirat 2 Hill Adibasi/Janjati 2
Others 3 Window/Widower 3 Buddhist 3 Hill Dalit 3
Divorced/Separate 4 Islam 4 Terai Adibasi/Janjati 4
Not applicable<10 years 5 Christian 5 TeraiDalit 5
Others 6 Terai Brahmin/Chetri 6
Muslim 7
Terai/Madhesi other caste 8
Others 9
 Literacy Type of school Occupation
Illeterate 1 Government 1 Agricultural worker 1
Informal 2 Private 2 Unskilled worker 2
Formal 3 No schooling 3 Semiskilled 3
Not applicable <6 years 4 Others 4 Skilled 4
Not applicable <6 years 5 Professional 5
Business 6
Student 7
Unemployed 8
House maker 9
Retired 10
Migrant worker 11
Not applicable <10 years 12
Others 13
Illness within one year Land holding(Kattha) Type of family
Yes 1 no land 0 Nuclear 1
No 2 <20 1 Joint 2
20-99 2
100-200 3
>200 4
Type of house Mother tongue Nearest health facility Birth within one year
Kachcha 1 Nepali 1 <30 min 1 Yes
Semi Pakka 2 Limbu 2 >30 min 2 No
Pakka 3 Rai 3
Tamang 4
Others 5
thin one year If birth, Sex of baby Death within one year If death, sex of the person
1 Male 1 Yes 1 Male
2 Female 2 No 2 Female
 Water source Distance of water source Processing of water
1 Tubewell 1 <50 meter 1 Yes 1
2 River/Stream 2 51-500 meter 2 No 2
Tap water 3 >500 meter 3
Well 4
Ponds 5
Others 6
Method of processing Wash hands with? Bath how often?
Boiling 1 Water only 1 Daily 1
Filter 2 Soap water 2 Every alternate day 2
Boil and Filter 3 Ash water 3 Once a week 3
Disinfection 4 Soil water 4 Twice a week 4
Others 5 No hand washing practice 5 Others 5
Others 6
Toilet present Toilet type Toilet use No toilet, defecate where?
Yes 1 Sanitary 1 Never 1 Open field
No 2 Unsanitary 2 Occasional 2 River
Always 3 Public toilet
Others
 ANC visit? If (yes) where? TD received
1 Yes 1 Private clinics 1 Yes 1
2 No 2 Government health facility 2 No 2
3 Others 3
4
If (yes)no of TD doses Taken Iron and folate during pregnancy
One 1 Iron only 1
Two 2 Folic acid only 2
Both 3
Not taken 4
Food consumption during pregnancy Food avoided during pregnancy
More 1 Yes 1
Same 2 No 2
Less 3
Special foods during pregnancy Place of delivery Attendant if home delivery
Yes 1 Home 1 SBA
No 2 Hospital/Health Institution 2 Non SBA
Family member
Relatives
Neighbour
Others
 Use of delivery kit in home delivery cord cut with Stump application
1 Yes 1 strile blade 1
2 No 2 kitchen knife 2
3 sickle 3
4
5
6
FP methods spontaneous/probed Ever used modern FP methods
Condom 1 Yes 1
Pills 2 No 2
Depo 3
IUD(CuT) 4
Norplant 5
Male sterilization 6
Female sterilization 7
 Which method Current use of modern FP methods Which method
Condom 1 Yes 1 Condom
Pills 2 No 2 Pills
Depo 3 Depo
IUD(CuT) 4 IUD(CuT)
Norplant 5 Norplant
Male sterilization 6 Male sterilization
Female sterilization 7 Female sterilization
 Child's first feed
1 Colostrum/Breast milk
2 Animal Milk
3 Medical/commercial preparation
4 Others
5
6
7
If not given colostrum,reason for not giving colostrum
1 No secretion
2 Others
3
4
 Supplementary milk feed Solid food fed BCG Rota I
1 Yes 1 Yes 1 Yes 1 Yes
2 No 2 No 2 No 2 No
 Rota II OPV I OPV II OPV III FIPV I
1 Yes 1 Yes 1 Yes 1 Yes 1 Yes
2 No 2 No 2 No 2 No 2 No
 FIPV II PCV I PCV II PCV III MR I
1 Yes 1 Yes 1 Yes 1 Yes 1 Yes
2 No 2 No 2 No 2 No 2 No
 MR II JE TCV Source of Information
1 Yes 1 Yes 1 Yes 1 Verbal 1
2 No 2 No 2 No 2 EPI Card 2
Child aged 12-23 months immunized fully or not? Type of Illness
Yes 1 URTI 1
No 2 LRTI 2
Skin Disease 3
Eye problem 4
Ear infection 5
Diarrhoea 6
Injury 7
Acid peptic disease 8
Fever 9
UTI 10
HTN 11
DM 12
TB 13
Malaria 14
Place of treatment Outcome Any history of disease in family
Government 1 Treatment ongoing 1 Hypertension 1
Private 2 Recovered 2 Diabetics 2
Tuberculosis 3
Coronary heart disease 4
Cancer 5
Leprosy 6
Others 7
Preference for treatment Rating of service Enrollment in health insurance scheme
Government health facility 1 Excellent 1 Yes
Private institurions 2 Very good 2 No
Local drug shop 3 Good 3
Traditional healer 4 Ok 4
Others 5 Poor 5
Very poor 6
 Overall satisfaction of insurance program Injury in six months
1 Very satisfied 4 Yes 1
2 Satisfied 3 No 2
Neutral 2
Dissatisfied 1
Injury causing disability Mechansim of injury Physical nature of injury
Yes 1 RTA 1 Fracture
No 2 Fall 2 Sprain/strain
Agricultural 3 Dislocation
Electrical shock 4 Cut, Bite or other open wound
Gunshot 5 Bruise or superficial injury
Drowning 6 Burn
Burn 7 Poisoning
Struck/Hit by person or object 8 Concussion/Head injury
Stab 9 Internal organ injury
Animal bite 10 Unknown
Poisoning 11 Others
Others 12
 Place of injury Death due to injury in 1 year
1 Home 1 Yes 1
2 Farm 2 No 2
3 Industry 3
4 Cinema/Theatre 4
5 Road in town 5
6 Road in village 6
7 Public/office building 7
8 School 8
9 Sports 9
10 Other 10
11
Sex of deceased Income per person per day/poverty line Clean teeth
Male 1 <1.95$ 1 Yes
Female 2 >=1.95$ 2 No
 If yes Clean with Fluoride content
1 Brush and toothpaste 1 Fluoridated 1
2 Brush and tooth powder 2 Non fluoridated 2
Brush only 3 Cant say 3
Fingers and toothpaste 4
Fingers and tooth powder 5
Fingers only 6
Datiwan 7
Other (specify) 8
 When do you brush Change toothbrush Oral hygiene aids
Before beakfast 1 1-3 months 1 Dental Floss
After breakfast and after dinner 2 4-6 months 2 Interdental brush
Before beakfast and after dinner 3 More than 6 months 3 Toothpicks
After every meal 4 Fluoride moth rinse
other
Any other 5
 E2 Ever had dental problem? E.2.1 Pain E.2.1Bleeding gums_dental problems
1 Yes 1 Yes 1 Yes
2 No 2 No 2 No
3
4
5
6
7
8
 Swollen gums_dental problems Missing tooth_dental problems
1 Yes 1 Yes 1
2 No 2 No 2
Foul breath_dental problems Mal-aligned teeth_dental problems Other dental problem
Yes 1 Yes 1 Yes
No 2 No 2 No
 E.2.2 No_consultation Friend_consulted Relative_consulted
1 Yes 1 Yes 1 Yes 1
2 No 2 No 2 No 2
Medical practitioner_consulted Pharmacist_consulted Trained dentist_consulted
Yes 1 Yes 1 Yes
No 2 No 2 No
 Untrained dentist_consulted Other consulted E.2.3 Treatment
1 Yes 1 Yes 1 Filling
2 No 2 No 2 Cleaning
Prosthesis
Cosmetic correction
Others
 E.3.1 Tooth decay_common problems Gum disease_common problems
1 Yes 1 Yes 1
2 No 2 No 2
3
4
5
Bad smell_common problems Crooked teeth_common problems
Yes 1 Yes 1
No 2 No 2
Mouth ulcers_common problems Stained teeth_common problems
Yes 1 Yes 1
No 2 No 2
Don't know common problems Other common problems E.3.2 Sweets_factors
Yes 1 Yes 1 Yes
No 2 No 2 No
 Not brushing regularly_factors Not rinsing_factors Tobacco_factors
1 Yes 1 Yes 1 Yes
2 No 2 No 2 No
 Don't know_factors Other factors
1 Yes 1 Yes 1
2 No 2 No 2
E.4.1 Paan_Knowledge Tobacco substance Chilim_Knowledge Tobacco substance
Yes 1 Yes 1
No 2 No 2
Gutka_Knowledge Tobacco substance Hookah_Knowledge Tobacco substance
Yes 1 Yes 1
No 2 No 2
Thambaku_Knowledge Tobacco substance Cigarette_Knowledge Tobacco substance
Yes 1 Yes 1
No 2 No 2
Bidi_Knowledge Tobacco substance E.4.2 Media_knowledge Source
Yes 1 Yes 1
No 2 No 2
Friends_knowledge Source Academics_knowledge Source Others _knowledge Source
Yes 1 Yes 1 Yes
No 2 No 2 No
 E.4.3 Paan_use Chilim_use Gutka_use Hookah_use
1 Never 1 Never 1 Never 1 Never 1
2 Not regularly 2 Not regularly 2 Not regularly 2 Not regularly 2
Daily 3 Daily 3 Daily 3 Daily 3
Tumbaku_use Cigarette_use Bidi_use E.4.4 No_benefit
Never 1 Never 1 Never 1 Yes 1
Not regularly 2 Not regularly 2 Not regularly 2 No 2
Daily 3 Daily 3 Daily 3
Don't Know_benefit Fresh breath_benefit Digestion_benefit Purify blood_benefit
Yes 1 Yes 1 Yes 1 Yes
No 2 No 2 No 2 No
 Strengthen teeth_benefit Taste good_benefit Feeling well_benefit
1 Yes 1 Yes 1 Yes 1
2 No 2 No 2 No 2
Others_benifit E.4.6 Paan_long effect Chilim_long effect Gutka_long effect
Yes 1 None 1 None 1 None
No 2 Don't Know 2 Don't Know 2 Don't Know
Cancer 3 Cancer 3 Cancer
Addiction 4 Addiction 4 Addiction
Others 5 Others 5 Others
 Hookah_long effect Tumbaku_long effect Cigarette_long effect
1 None 1 None 1 None 1
2 Don't Know 2 Don't Know 2 Don't Know 2
3 Cancer 3 Cancer 3 Cancer 3
4 Addiction 4 Addiction 4 Addiction 4
5 Others 5 Others 5 Others 5
Bidi_long effect E.4.6.1 If cancer_site E.4.7 Paan_immediate ill effect
None 1 Gums 1 None 1
Don't Know 2 Tongue 2 Don’t know 2
Cancer 3 Inner cheek 3 Increased salivation 3
Addiction 4 Throat 4 Nausea/Vomitting 4
Others 5 Lungs 5 Anxiety 5
Others 6 Chest pain/breathlessness 6
Stomach cramps 7
Others 8
Chilim_immediate ill effect Gutka_immediate ill effect Hookah_immediate ill effect
None 1 None 1 None
Don’t know 2 Don’t know 2 Don’t know
Increased salivation 3 Increased salivation 3 Increased salivation
Nausea/Vomitting 4 Nausea/Vomitting 4 Nausea/Vomitting
Anxiety 5 Anxiety 5 Anxiety
Chest pain/breathlessness 6 Chest pain/breathlessness 6 Chest pain/breathlessness
Stomach cramps 7 Stomach cramps 7 Stomach cramps
Others 8 Others 8 Others
 Tumbaku_immediate ill effect
1 None
2 Don’t know
3 Increased salivation
4 Nausea/Vomitting
5 Anxiety
6 Chest pain/breathlessness
7 Stomach cramps
8 Others
Cigarette_immediate ill effect
1 None 1
2 Don’t know 2
3 Increased salivation 3
4 Nausea/Vomitting 4
5 Anxiety 5
6 Chest pain/breathlessness 6
7 Stomach cramps 7
8 Others 8
 Bidi_immediate ill effect E.4.8 Possible to quit
None 1 Yes 1
Don’t know 2 No 2
Increased salivation 3 Don’t know 3
Nausea/Vomitting 4
Anxiety 5
Chest pain/breathlessness 6
Stomach cramps 7
Others 8
E.4.9 Support required to leave substances E.4.10 Source of embarrassment
Don’t know 1 Yes 1
Personal motivation 2 No 2
Encouragement 3 Don’t know 3
Alternative recreation 4
Increased knowledge 5
Others 6
E.4.11 Use allowed in adolescent E.4.12 Advertisement ban
Yes 1 Yes 1
No 2 No 2
Don’t know 3 Don’t know 3
E.4.13 Production/sale ban
Yes 1
No 2
Don’t know 3