PDF, 1536K - Measure DHS

463 Has (NAME) been ill with a fever at any time
in the last 2 weeks?
464 Has (NAME) had an illness with a cough at
any time in the last 2 weeks?
465 When (NAME) had an illness with a cough,
did he/she breathe faster than usual with
short, fast breaths?
LAST BIRTH
NAME _______________________
YES .................................................. 1
NO.................................................... 2
DON’T KNOW .................................. 8
YES .................................................. 1
NO.................................................2
(SKIP TO 466)
DON’T KNOW ...............................8
YES .................................................. 1
NO.................................................... 2
DON’T KNOW .................................. 8
NEXT-TO-LAST BIRTH
NAME _______________________
YES ................................................. 1
NO ................................................... 2
DON’T KNOW ................................. 8
YES ................................................. 1
NO ................................................ 2
(SKIP TO 466)
DON’T KNOW .............................. 8
YES ................................................. 1
NO ................................................... 2
DON’T KNOW ................................. 8
466 CHECK 463 AND 464:
FEVER OR COUGH?
“YES” IN
463
OR 464
OTHER
(SKIP TO 472)
“YES” IN
463
OR 464
OTHER
(SKIP TO 472)
467 Did you seek advice or treatment for the
fever/cough?
YES..................................................1
NO.................................................2
(SKIP TO 472)
YES..................................................1
NO ................................................ 2
(SKIP TO 472)
468 Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.
469 CHECK 463:
HAD FEVER?
GOVERNMENT
HOSPITAL ...................................A
HEALTH CENTER .......................B
HEALTH STATION/CLINIC..........C
HEALTH POST ............................D
COMMUNITY-BASED OUTLET ..E
OTHER GOV’T _____________ F
(SPECIFY)
NONGOVERNMENTAL (NGO)
NGO HEALTH FACILITY............ G
COMMUNITY-BASED OUTLET ..H
OTHER NGO ______________ I
(SPECIFY)
PRIVATE MEDICAL
PVT. HOSPITAL .......................... J
PVT.DOCTOR/CLINIC.................K
PHARMACY................................. L
OTHER PVT.
MEDICAL _______________ M
(SPECIFY)
OTHER SOURCE
DRUG VENDOR ..........................N
SHOP .......................................... O
TRAD. PRACTITIONER...............P
OTHER
X
(SPECIFY)
“YES” IN 463 “NO”/”DK” IN 463
(SKIP TO 472)
GOVERNMENT
HOSPITAL...................................A
HEALTH CENTER ......................B
HEALTH STATION/CLINIC.........C
HEALTH POST ...........................D
COMMUNITY-BASED OUTLET..E
OTHER GOV’T ____________ F
(SPECIFY)
NONGOVERNMENTAL (NGO)
NGO HEALTH FACILITY ........... G
COMMUNITY-BASED OUTLET..H
OTHER NGO _______________ I
(SPECIFY)
PRIVATE MEDICAL
PVT. HOSPITAL.......................... J
PVT.DOCTOR/CLINIC ................K
PHARMACY ................................ L
OTHER PVT.
MEDICAL ______________ M
(SPECIFY)
OTHER SOURCE
DRUG VENDOR..........................N
SHOP ......................................... O
TRAD. PRACTITIONER ..............P
OTHER
X
(SPECIFY)
“YES” IN 463 “NO”/”DK” IN 463
(SKIP TO 472)
470 Did (NAME) take any drugs for the fever? YES .................................................. 1
NO.................................................2
(SKIP TO 472)
DON’T KNOW ...............................8
YES ................................................. 1
NO ................................................ 2
(SKIP TO 472)
DON’T KNOW .............................. 8