BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

364 Pattern. of Mortalityin Childhood
INTER-AMERICAN INVESTIGATION OF MORTALITY IN CHILDHOOD
Confidential Death - page 3
Name of child
Serial no.
Date of Date of Sex Age at
death yrs. emo. days hrs.
birth
death
39. During the past year, has this child been attended by a ph ician or in a clinic or hospital? YesO No 0 Unknown 0
Days in
Number
Name of physician, clinic or hospital Type* Dates hospital Reason vie ta
*Indicate whether clinic (health center or hospital) C, in-patient in hospital H, practicing physician P, emergency E.
40. Did the child receive medical attention before the past year? Yes 0 No 0 Unknown 0
Reason
Number
Days in
Name of physician, clinic or hospital Type* Dates hospital visits
*Indicate whether clinic (health center or hospital) C, In-patient in hospital H. practicing physician P, emergency E.
41. Disease a) How long was the child ill?
b) How did illness start?
c) What disease do you think caused the child's death?
42. Description of the disease by the mother
43. Home treatment
44. Prescriptions
45. Who prescribed?
46. Did the mother see signs of malnutrition? (edema, loss of weight, changes in hair or skin)
47. To doctor a) Was child taken to doctor? No 0 Yes 0 b) How many days after onset of illness? ­
c) What was condition of child? Slightly ill 0 Moderately il 0 Very ill 0
48. Where did child die? Home 0 Hospital 03 Name Other 03
49. Death certificate number
50. Source of information: Mother 0 FatherO Other 0
Date
Interviewer