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cHSCK F<br />

CHECK G<br />

Q13<br />

Q13A<br />

Q13A<br />

CHX F<br />

CNK G<br />

Q13<br />

Q13A1<br />

Q13A2<br />

No of<br />

sOxM/<br />

Characters<br />

2<br />

2<br />

2<br />

2<br />

2<br />

Codang Instructions/ Ramarks<br />

~es .- 02<br />

How long ago was oparation-<br />

E~ther Lees than 2 years 01<br />

2 years or more . .. . . 02<br />

Pr9gnant 7<br />

Informant Pragnant .. 01<br />

Othars ......... .... 02<br />

~<br />

U3 Lng any cOntrac*pt Lva<br />

mathode when you baceme<br />

prmgnant ?<br />

Yas .. .. ... ...... ... 01<br />

No ................. .. .. 02<br />

Values .- U<br />

TYPO of COntracept ive met hod<br />

Withdrawal ............ 01<br />

Sheath fcondom . ..... . 02<br />

Safe par~od/rhythm<br />

method ................ 03<br />

Cap/dLaphragm ... .. .... 04<br />

contracapt~ve sponge ... 05<br />

HLnL pLll ........... 06<br />

Combmed pLll (inc<br />

mult~phas Lc ) .......... 07<br />

pLll . not sure Lf man~<br />

orcOmb Lned . ..... ... 08<br />

IuD/cOLl/LntrautmrLn*<br />

d-vice ................ 09<br />

Foams , g019 , Spray- ,<br />

pacsarias (s~rmic~das ) 10<br />

In]mctxmn ............. 12<br />

Another method (Sp+clf y) 13<br />

Valu-s -3-11<br />

Code as Q13A1<br />

151

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