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indian council of medical research - Pondicherry University DSpace ...

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School chlldren nlorbldily SA Form 2 Morbldlty Survey<br />

I General lnfor~nat~on<br />

1 ldentilicatlon data Date<br />

Name Aye Sex ID No<br />

Father 4 Nar.1-<br />

Mothers Name<br />

Strp-t<br />

Household No<br />

2. Place <strong>of</strong> exarr~tr~ation ...................... School \ Home<br />

Il al II-~IIIL, :,I i' whe 111. 1 .<br />

i I iI~?eril~c~ \ Nut enrolled<br />

3. Information frorn teaclret<br />

Is this r Iilirl soifr3rrln lr,vr> any rnoibid~ty Yes \ No<br />

If yes !lie rlatlirr <strong>of</strong> rnoibldlty 1) .....................<br />

2) ..............<br />

11. Cll~lic:>l blislry<br />

1. Hnstory <strong>of</strong> illr~ess dtrrlrry tllr psbl 2 weeks . . ..Yes \ No<br />

If YP? , tljr I?:\IIIII. <strong>of</strong> IIIIIPT~', i l l t llln!!l~~a \ nbd pain \ fever \ I~cndnche<br />

,',.i2 '! ear \ skin \others<br />

Ccta~ls <strong>of</strong> ~llness: Duration ......<br />

Sgwerily . . . . . mtld \mod \ sev<br />

hospitalhsed<br />

Yes \No<br />

No, <strong>of</strong> school days lost ....................<br />

others<br />

2. History 01 passing worms during the past 1 month . Yes \ No<br />

Hislory <strong>of</strong> passlrq worms durmg the past 6 months . . .Yes \ No<br />

(excludtilg the prevlous one month )<br />

If Yes, the nature <strong>of</strong> warms passed . . . . Big \ Small pink \ whlte<br />

3. History <strong>of</strong> taking treatment for chronic diseases ..... Yes \ No<br />

If Yes, for what disease? ...........................................

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