|
1 |
[record_id] |
Record ID |
text |
|
2 |
[name_of_interviwer] |
Name of Interviwer |
text, Required Field Annotation: @APPUSERNAME-APP |
|
3 |
[date_of_survey] |
Date of survey
|
text (date_dmy), Required Field Annotation: @TODAY-UTC |
|
4 |
[rch_id] |
RCH id (to be given by ASHA)
|
text (number), Required |
|
5 |
[name_of_the_mother] |
Name of the mother
|
text, Required |
|
6 |
[name_of_spouse] |
Name of spouse
|
text, Required |
|
7 |
[phone_number_pg] |
Phone Number of pregnant women 1 |
text (integer, Min: 5555555555, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
8 |
[phone_number_2] |
Phone Number of pregnant women 2
if second no is not available (9999999999)
|
text (integer, Min: 5555555555, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
9 |
[age_in_years] |
Age (in years)
|
text (number), Required |
|
10 |
[lmp] |
LMP
|
text (date_dmy), Required |
|
11 |
[edd] |
EDD
|
text (date_dmy), Required |
|
12 |
[gestational_age_in_weeks] |
Gestational age (in weeks)
|
text (integer), Required |
|
13 |
[gravida] |
Gravida
|
text (integer), Required |
|
14 |
[parity] |
Parity
|
text (number), Required |
|
15 |
[living] |
No of children living |
text (integer), Required |
|
16 |
[type_of_resident] |
Type of resident |
radio, Required1 | Permanent | 2 | Migrant (long term - more than a year - from other state) | 3 | Migrant (short term - less than 6 months - from other state) |
|
|
17 |
[previous_pregnancy_history] |
Previous Pregnancy History |
descriptive |
|
18 |
[previous_history_of_stillb] |
Previous history of stillbirth
|
yesno, Required |
|
19 |
[count_stillbirth]
Show the field ONLY if:
[previous_history_of_stillb] = '1'
|
specify the count |
text (integer), Required |
|
20 |
[previous_history_of_neonat] |
Previous history of Neonatal death
|
yesno, Required |
|
21 |
[count_neonatal]
Show the field ONLY if:
[previous_history_of_neonat] = '1'
|
Specify the count |
text (number), Required |
|
22 |
[history_of_aborti] |
Previous history of Abortions
|
yesno, Required |
|
23 |
[count_aborstion]
Show the field ONLY if:
[history_of_aborti]="1"
|
specify the count |
text (integer), Required |
|
24 |
[previous_history_of_lscs] |
Previous history of LSCS
|
yesno, Required |
|
25 |
[count_lscs]
Show the field ONLY if:
[previous_history_of_lscs] = '1'
|
specify the count |
text (number), Required |
|
26 |
[history_of_any_illness_at] |
History of any illness at any time during previous pregnancy
|
yesno, Required |
|
27 |
[illness]
Show the field ONLY if:
[history_of_any_illness_at] = '1'
|
What was the illness? (Multiple responses are possible) |
checkbox, Required1 | illness___1 | Diabetes | 2 | illness___2 | Hypertension | 3 | illness___3 | Eclampsia/ Pre-eclampsia | 4 | illness___4 | Thyroid disease | 5 | illness___5 | pre-existing medical conditions such as heart disease, kidney disease, or epilepsy | 6 | illness___6 | Allergy | 7 | illness___7 | TB | 8 | illness___8 | HIV | 9 | illness___9 | Fever with rash | 10 | illness___10 | Severe Anemia / Hb less than 7 g/dl | 11 | illness___11 | Excessive bleeding (antepartum) | 12 | illness___12 | Others |
|
|
28 |
[specify_illness]
Show the field ONLY if:
[illness(12)] = '1'
|
Specify |
text, Required |
|
29 |
[anc_details] |
ANC details |
descriptive |
|
30 |
[registered_with_health_facili] |
Have you registered with any health facility for ANC during this pregnancy?
|
yesno, Required |
|
31 |
[no_of_anc_visits_done]
Show the field ONLY if:
[registered_with_health_facili] = '1'
|
No. of ANC visits done till now
|
text (integer), Required |
|
32 |
[type_of_facility]
Show the field ONLY if:
[registered_with_health_facili] = '1'
|
Type of facility
|
radio, Required1 | Public/government facility | 2 | Private facility | 3 | Semi/aided facility | 4 | Other |
|
|
33 |
[other_health_facility]
Show the field ONLY if:
[type_of_facility] = '4'
|
Other |
text, Required |
|
34 |
[month_preg_in_anc_done]
Show the field ONLY if:
[registered_with_health_facili] = '1'
|
In which month of your pregnancy did you have the first ANC visit (for your current pregnancy)?
|
text (integer), Required |
|
35 |
[most_recent_anc] |
When was your most recent ANC visit?
|
radio, Required1 | Less than 1 week ago | 2 | Between 2-4 weeks ago | 3 | More than 1 month ago | 4 | Never had an ANC visit | 5 | Others specify |
|
|
36 |
[other_recent_anc]
Show the field ONLY if:
[most_recent_anc] = '5'
|
Other |
text, Required |
|
37 |
[clinical_tests_conducted_i] |
Clinical Tests Conducted in the ANC visit |
descriptive |
|
38 |
[height_checked] |
Height checked |
yesno, Required |
|
39 |
[were_you_informed_about_th]
Show the field ONLY if:
[height_checked] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
40 |
[value_of_height_in_cm]
Show the field ONLY if:
[were_you_informed_about_th] = '1'
|
Value of height in cm
|
text (number), Required |
|
41 |
[any_hrp_complication_ht]
Show the field ONLY if:
[height_checked] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
42 |
[medicines_treatment_provid_ht]
Show the field ONLY if:
[any_hrp_complication_ht] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
43 |
[referred_hrp_ht]
Show the field ONLY if:
[any_hrp_complication_ht] = '1'
|
Referred
|
yesno, Required |
|
44 |
[weight_checked] |
Weight Checked |
yesno, Required |
|
45 |
[informed_about_wt]
Show the field ONLY if:
[weight_checked] = '1'
|
Were you informed about the result? |
yesno, Required |
|
46 |
[value_wt]
Show the field ONLY if:
[informed_about_wt] = '1'
|
Value in Kg |
text (integer), Required |
|
47 |
[was_any_hrp_complication_i]
Show the field ONLY if:
[weight_checked] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
48 |
[medicines_treatment_provid_wt]
Show the field ONLY if:
[was_any_hrp_complication_i] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
49 |
[referred_wt]
Show the field ONLY if:
[was_any_hrp_complication_i] = '1'
|
Referred
|
yesno, Required |
|
50 |
[blood_pressure] |
Blood Pressure checked |
yesno, Required |
|
51 |
[were_you_informed_about_bp]
Show the field ONLY if:
[blood_pressure] = '1'
|
Were you informed about the result? (Skip if Not checked)
|
yesno, Required |
|
52 |
[value_bp]
Show the field ONLY if:
[were_you_informed_about_bp] = '1'
|
Value
|
text, Required |
|
53 |
[hrp_complication_bp]
Show the field ONLY if:
[blood_pressure] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
54 |
[medicines_treatment_provid_bp]
Show the field ONLY if:
[hrp_complication_bp] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
55 |
[referred_bp]
Show the field ONLY if:
[hrp_complication_bp] = '1'
|
Referred
|
yesno, Required |
|
56 |
[abdominal_check_up] |
Abdominal check up
|
yesno, Required |
|
57 |
[were_you_informed_abdomin]
Show the field ONLY if:
[abdominal_check_up] = '1'
|
were you informed about the result? (Skip if Not checked)
|
yesno, Required |
|
58 |
[value]
Show the field ONLY if:
[were_you_informed_abdomin] = '1'
|
Value |
text, Required |
|
59 |
[hrp_complication_abdomin]
Show the field ONLY if:
[abdominal_check_up] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
60 |
[medicines_treatment_abdomin]
Show the field ONLY if:
[hrp_complication_abdomin] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
61 |
[referred_abdomin]
Show the field ONLY if:
[hrp_complication_abdomin] = '1'
|
Referred
|
yesno, Required |
|
62 |
[investigation_done_in_the] |
Investigation done in the ANC visit |
descriptive |
|
63 |
[hemoglobin] |
Hemoglobin
|
yesno, Required |
|
64 |
[were_you_informed_about_hb]
Show the field ONLY if:
[hemoglobin] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
65 |
[value_hb]
Show the field ONLY if:
[were_you_informed_about_hb] = '1'
|
Value |
text (number), Required |
|
66 |
[hrp_complication_hb]
Show the field ONLY if:
[hemoglobin] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
67 |
[medicines_hb]
Show the field ONLY if:
[hrp_complication_hb] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
68 |
[referred_hb]
Show the field ONLY if:
[hrp_complication_hb] = '1'
|
Referred |
yesno, Required |
|
69 |
[blood_glucose_sugar_rbs_or] |
Blood Glucose/Sugar (RBS or fasting or OGTT)
|
yesno, Required |
|
70 |
[informed_rbs]
Show the field ONLY if:
[blood_glucose_sugar_rbs_or] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
71 |
[value_rbs]
Show the field ONLY if:
[informed_rbs] = '1'
|
Value
|
text (integer), Required |
|
72 |
[hrp_complication_rbs]
Show the field ONLY if:
[blood_glucose_sugar_rbs_or] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
73 |
[medicines_treatment_rbs]
Show the field ONLY if:
[hrp_complication_rbs] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
74 |
[referred_rbs]
Show the field ONLY if:
[hrp_complication_rbs] = '1'
|
Referred
|
yesno, Required |
|
75 |
[urine_test] |
Urine Test
|
yesno, Required |
|
76 |
[were_you_informed_urne]
Show the field ONLY if:
[urine_test] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
77 |
[hrp_complication_urn]
Show the field ONLY if:
[urine_test] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
78 |
[medicines_treatment_urne]
Show the field ONLY if:
[hrp_complication_urn] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
79 |
[referred_urn]
Show the field ONLY if:
[hrp_complication_urn] = '1'
|
Referred
|
yesno, Required |
|
80 |
[usg] |
USG
|
yesno, Required |
|
81 |
[informed_about_usg]
Show the field ONLY if:
[usg] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
82 |
[hrp_complication_usg]
Show the field ONLY if:
[usg] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
83 |
[medicines_treatment_usg]
Show the field ONLY if:
[hrp_complication_usg] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
84 |
[referred_usg]
Show the field ONLY if:
[hrp_complication_usg] = '1'
|
Referred
|
yesno, Required |
|
85 |
[danger_signs] |
Danger Signs |
descriptive |
|
86 |
[did_you_experience_any_of] |
"Did you experience any of the following danger signs during anytime of the pregnancy? |
checkbox, Required1 | did_you_experience_any_of___1 | Vaginal Bleeding | 2 | did_you_experience_any_of___2 | Severe Headaches | 3 | did_you_experience_any_of___3 | Blurred Vision | 4 | did_you_experience_any_of___4 | Reduced fetal movements | 5 | did_you_experience_any_of___5 | Excessive swelling in face or hands or feet | 6 | did_you_experience_any_of___6 | Convulsions | 7 | did_you_experience_any_of___7 | Fever | 8 | did_you_experience_any_of___8 | Severe Abdominal Pain | 9 | did_you_experience_any_of___9 | Dizziness and Lightheadedness | 10 | did_you_experience_any_of___10 | Fatigue and Weakness | 11 | did_you_experience_any_of___11 | Fast or difficult Breathing/shortness of breath | 12 | did_you_experience_any_of___12 | No | 13 | did_you_experience_any_of___13 | Any other |
|
|
87 |
[specify_dangersign]
Show the field ONLY if:
[did_you_experience_any_of(13)] = '1'
|
Specify |
text, Required |
|
88 |
[if_experienced_any_danger]
Show the field ONLY if:
[did_you_experience_any_of(1)] = '1' OR [did_you_experience_any_of(2)] = '1' OR [did_you_experience_any_of(3)] = '1' OR [did_you_experience_any_of(4)] = '1' OR [did_you_experience_any_of(5)] = '1' OR [did_you_experience_any_of(6)] = '1' OR [did_you_experience_any_of(7)] = '1' OR [did_you_experience_any_of(8)] = '1' OR [did_you_experience_any_of(9)] = '1' OR [did_you_experience_any_of(10)] = '1' OR [did_you_experience_any_of(11)] = '1' or [did_you_experience_any_of(13)] = '1'
|
If experienced any danger sign, how did you manage it? |
radio, Required1 | At home | 2 | Visited government facility | 3 | Visited private facility | 4 | Consulted religious practitioners |
|
|
89 |
[registration_form_7th_month_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
|
90 |
[date_of_survey_eight] |
Date of survey
|
text (date_dmy), Required Field Annotation: @NOW |
|
91 |
[name_of_interviwer_eight] |
Name of interviwer |
text Field Annotation: @APPUSERNAME-APP |
|
92 |
[rch_id_eight] |
RCH id |
text |
|
93 |
[phone_number_eight_one] |
Phone number pregnant women 1 |
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
94 |
[phone_number_eight_one_2] |
Phone number pregnant women 2 if second no is not available (9999999999)
|
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
95 |
[anc_details_eight] |
ANC details |
descriptive |
|
96 |
[gestational_age_in_eight] |
Gestational age (in weeks)
|
text (number), Required |
|
97 |
[anc_visit_mnth_eight] |
Did you have an ANC visit for this month?
|
radio, Required1 | Yes | 2 | Could not go | 3 | Did not think it was needed | 4 | Didn't know it was due | 5 | other reasons |
|
|
98 |
[reason_anc_vst_eight]
Show the field ONLY if:
[anc_visit_mnth_eight] = '5'
|
Reason |
text, Required |
|
99 |
[date_of_anc_visit_eight]
Show the field ONLY if:
[anc_visit_mnth_eight] = '1'
|
Date of ANC visit
|
text (date_dmy), Required |
|
100 |
[type_of_facility_eight]
Show the field ONLY if:
[anc_visit_mnth_eight] = '1'
|
Type of facility
|
radio, Required1 | Public/government facility | 2 | Private facility | 3 | Semi/aided facility | 4 | Other |
|
|
101 |
[other_plc_anc_vst_eight]
Show the field ONLY if:
[type_of_facility_eight] = '4'
|
Other |
text, Required |
|
102 |
[clinical_tests_conducted_eight] |
Clinical Tests Conducted in the ANC visit |
descriptive |
|
103 |
[weight_ckd_eight] |
Weight Checked
|
yesno, Required |
|
104 |
[informed_abt_wt_eight]
Show the field ONLY if:
[weight_ckd_eight] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
105 |
[value_wt_eight]
Show the field ONLY if:
[informed_abt_wt_eight] = '1'
|
Value in Kg |
text (integer), Required |
|
106 |
[hrp_complication_wt_eight]
Show the field ONLY if:
[weight_ckd_eight] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
107 |
[medicines_treat_wt_et]
Show the field ONLY if:
[hrp_complication_wt_eight] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
108 |
[referred_wt_et]
Show the field ONLY if:
[hrp_complication_wt_eight] = '1'
|
Referred
|
yesno, Required |
|
109 |
[bp_ckd_et] |
Blood Pressure Checked |
yesno, Required |
|
110 |
[informed_abt_bp_et]
Show the field ONLY if:
[bp_ckd_et] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
111 |
[value_bp_et]
Show the field ONLY if:
[informed_abt_bp_et] = '1'
|
Value blood pressure |
text, Required |
|
112 |
[hrp_complication_bp_et]
Show the field ONLY if:
[bp_ckd_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
113 |
[medicines_provid_bp_et]
Show the field ONLY if:
[hrp_complication_bp_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
114 |
[referred_bp_et]
Show the field ONLY if:
[hrp_complication_bp_et] = '1'
|
Referred |
yesno, Required |
|
115 |
[abdominal_check_up_et] |
Abdominal check up done
|
yesno, Required |
|
116 |
[informed_abt_abd_et]
Show the field ONLY if:
[abdominal_check_up_et] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
117 |
[value_abd_et]
Show the field ONLY if:
[informed_abt_abd_et] = '1'
|
Value
|
text, Required |
|
118 |
[hrp_complication_abd_et]
Show the field ONLY if:
[abdominal_check_up_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
119 |
[medicines_treatment_abd_et]
Show the field ONLY if:
[hrp_complication_abd_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
120 |
[referred_abd_et]
Show the field ONLY if:
[abdominal_check_up_et] = '1'
|
Referred |
yesno, Required |
|
121 |
[investigation_done_in_et] |
Investigation done in the ANC visit |
descriptive |
|
122 |
[hb_et] |
Hemoglobin
|
yesno, Required |
|
123 |
[informed_abt_hb_et]
Show the field ONLY if:
[hb_et] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
124 |
[value_hb_et]
Show the field ONLY if:
[informed_abt_hb_et] = '1'
|
Value
|
text (integer), Required |
|
125 |
[hrp_complication_hb_et]
Show the field ONLY if:
[hb_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
126 |
[medicines_treatment_hb_et]
Show the field ONLY if:
[hrp_complication_hb_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
127 |
[referred_hb_et]
Show the field ONLY if:
[hrp_complication_hb_et] = '1'
|
Referred |
yesno, Required |
|
128 |
[rbs_et] |
Blood Glucose/Sugar (RBS or fasting or OGTT)
|
yesno, Required |
|
129 |
[informed_abt_rbs_et]
Show the field ONLY if:
[rbs_et] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
130 |
[value_rbs_et]
Show the field ONLY if:
[informed_abt_rbs_et] = '1'
|
Value |
text (number), Required |
|
131 |
[hrp_complication_rbs_et]
Show the field ONLY if:
[rbs_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
132 |
[medicines_provid_rbs_et]
Show the field ONLY if:
[hrp_complication_rbs_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
133 |
[referred_rbs_et]
Show the field ONLY if:
[hrp_complication_rbs_et] = '1'
|
Referred |
yesno, Required |
|
134 |
[urine_et] |
Urine Test
|
yesno, Required |
|
135 |
[informed_abt_urin_et]
Show the field ONLY if:
[urine_et] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
136 |
[hrp_complication_urn_et]
Show the field ONLY if:
[urine_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
137 |
[medicines_treat_urn_et]
Show the field ONLY if:
[hrp_complication_urn_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
138 |
[referred_urn_et]
Show the field ONLY if:
[medicines_treat_urn_et] = '1'
|
Referred |
yesno, Required |
|
139 |
[usg_et] |
USG is done |
yesno, Required |
|
140 |
[informed_about_usg_et]
Show the field ONLY if:
[usg_et] = '1'
|
Were you informed about the result? |
yesno, Required |
|
141 |
[hrp_complication_usg_et]
Show the field ONLY if:
[usg_et] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
142 |
[medicines_treatment_usg_et]
Show the field ONLY if:
[hrp_complication_usg_et] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
143 |
[referred_usg_et]
Show the field ONLY if:
[hrp_complication_usg_et] = '1'
|
Referred |
yesno, Required |
|
144 |
[danger_signs_et] |
Danger Signs |
descriptive |
|
145 |
[danger_sign_et] |
"Did you experience any of the following danger signs anytime after the last interview?
(Multiple responses can be selected)"
|
checkbox, Required1 | danger_sign_et___1 | Vaginal Bleeding | 2 | danger_sign_et___2 | Severe Headaches | 3 | danger_sign_et___3 | Blurred Vision | 4 | danger_sign_et___4 | Reduced fetal movements | 5 | danger_sign_et___5 | Excessive swelling in face or hands or feet | 6 | danger_sign_et___6 | Convulsions | 7 | danger_sign_et___7 | Fever | 8 | danger_sign_et___8 | Severe Abdominal Pain | 9 | danger_sign_et___9 | Dizziness and Lightheadedness | 10 | danger_sign_et___10 | Fatigue and Weakness | 11 | danger_sign_et___11 | Fast or difficult Breathing/shortness of breath | 12 | danger_sign_et___12 | No | 13 | danger_sign_et___13 | Any other |
|
|
146 |
[any_other_specify_et]
Show the field ONLY if:
[danger_sign_et(13)] = '1'
|
Any other specify |
text, Required |
|
147 |
[mange_danger_et]
Show the field ONLY if:
[danger_sign_et(1)] = '1' OR [danger_sign_et(2)] = '1' OR [danger_sign_et(3)] = '1' OR [danger_sign_et(4)] = '1' OR [danger_sign_et(5)] = '1' OR [danger_sign_et(6)] = '1' OR [danger_sign_et(7)] = '1' OR [danger_sign_et(8)] = '1' OR [danger_sign_et(9)] = '1' OR [danger_sign_et(10)] = '1' OR [danger_sign_et(11)] = '1' OR [danger_sign_et(13)] = '1'
|
How did you manage it?
|
radio, Required1 | At home | 2 | Visited government facility | 3 | Visited private facility | 4 | Consulted religious practitioners |
|
|
148 |
[st_followup_form_8th_month_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
|
149 |
[date_of_survey_9] |
Date of survey
|
text (date_dmy), Required |
|
150 |
[rch_id_nine] |
RCH id (to be given by ASHA)
|
text, Required |
|
151 |
[mobile_no_nine] |
Phone number of pregnant women no 1 |
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
152 |
[mobile_no_nine_2] |
Phone number of pregnant women no 2 if second no is not available (9999999999)
|
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
153 |
[anc_details_nine] |
ANC details |
descriptive, Required |
|
154 |
[gestational_nine] |
Gestational age (in weeks)
|
text (integer), Required |
|
155 |
[anc_vst_nine] |
Did you have an ANC visit for this month?
|
radio, Required1 | Yes | 2 | Could not go | 3 | Did not think it was needed | 4 | Didn't know it was due | 5 | other reasons |
|
|
156 |
[other_not_vst]
Show the field ONLY if:
[anc_vst_nine] = '5'
|
Other |
text, Required |
|
157 |
[date_of_anc_visit_nine]
Show the field ONLY if:
[anc_vst_nine] = '1'
|
Date of ANC visit
|
text (date_dmy), Required |
|
158 |
[type_of_facility_nine]
Show the field ONLY if:
[anc_vst_nine] = '1'
|
Type of facility
|
radio, Required1 | Public/government facility | 2 | Private facility | 3 | Semi/aided facility | 4 | Other |
|
|
159 |
[other_place_anc_vst_nine]
Show the field ONLY if:
[type_of_facility_nine] = '4'
|
Other |
text, Required |
|
160 |
[clinical_tests_conduct_nine] |
Clinical Tests Conducted in the ANC visit |
descriptive |
|
161 |
[weight_nine] |
Weight
|
yesno, Required |
|
162 |
[informed_about_wt_ni]
Show the field ONLY if:
[weight_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
163 |
[value_wt_ni]
Show the field ONLY if:
[informed_about_wt_ni] = '1'
|
Value in kgs |
text (integer), Required |
|
164 |
[hrp_complication_wt_nine]
Show the field ONLY if:
[weight_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
165 |
[medicines_treatmen_wt_nine]
Show the field ONLY if:
[hrp_complication_wt_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
166 |
[referred_wt_nine]
Show the field ONLY if:
[hrp_complication_wt_nine] = '1'
|
Referred
|
yesno, Required |
|
167 |
[bp_checked_nine] |
Blood Pressure checked |
yesno, Required |
|
168 |
[informed_abt_bp_nine]
Show the field ONLY if:
[bp_checked_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
169 |
[value_bp_nine]
Show the field ONLY if:
[informed_abt_bp_nine] = '1'
|
Value
|
text, Required |
|
170 |
[hrp_complication_bp_nine]
Show the field ONLY if:
[bp_checked_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
171 |
[medicines_tret_bp_nine]
Show the field ONLY if:
[hrp_complication_bp_nine] = '1'
|
Medicines / treatment provided
|
yesno, Required |
|
172 |
[referred_bp_nine]
Show the field ONLY if:
[hrp_complication_bp_nine] = '1'
|
Referred
|
yesno, Required |
|
173 |
[abdominal_check_up_done] |
Abdominal check up done
|
yesno, Required |
|
174 |
[informed_about_ad_nine]
Show the field ONLY if:
[abdominal_check_up_done] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
175 |
[value_ad_nine]
Show the field ONLY if:
[informed_about_ad_nine] = '1'
|
Value
|
text, Required |
|
176 |
[hrp_complication_ad_nine]
Show the field ONLY if:
[abdominal_check_up_done] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
177 |
[medicines_treatment_ab_nine]
Show the field ONLY if:
[hrp_complication_ad_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
178 |
[referred_ad_nine]
Show the field ONLY if:
[hrp_complication_ad_nine] = '1'
|
Referred
|
yesno, Required |
|
179 |
[hb_nine] |
Hemoglobin
|
yesno, Required |
|
180 |
[informed_hb_nine]
Show the field ONLY if:
[hb_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
181 |
[value_hb_nine]
Show the field ONLY if:
[informed_hb_nine] = '1'
|
Value
|
text (integer), Required |
|
182 |
[hrp_complication_hb_nine]
Show the field ONLY if:
[hb_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
183 |
[medicines_treatment_ad_nine]
Show the field ONLY if:
[hrp_complication_hb_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
184 |
[referred_hb_nine]
Show the field ONLY if:
[hrp_complication_hb_nine] = '1'
|
Referred |
yesno |
|
185 |
[rbs_nine] |
Blood Glucose/Sugar (RBS or fasting or OGTT)
|
yesno, Required |
|
186 |
[informed_abt_rbs_nine]
Show the field ONLY if:
[rbs_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
187 |
[value_rbs_nine]
Show the field ONLY if:
[informed_abt_rbs_nine] = '1'
|
Value
|
text, Required |
|
188 |
[hrp_complication_rbs_nine]
Show the field ONLY if:
[rbs_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
189 |
[medicines_treatment_rbs_nine]
Show the field ONLY if:
[hrp_complication_rbs_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
190 |
[referred_rbs_nine]
Show the field ONLY if:
[hrp_complication_rbs_nine] = '1'
|
Referred
|
yesno, Required |
|
191 |
[urine_nine] |
Urine Test
|
yesno, Required |
|
192 |
[informed_abt_urin_nine]
Show the field ONLY if:
[urine_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
193 |
[hrp_complication_urine_nine]
Show the field ONLY if:
[urine_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
194 |
[medicines_urine_nine]
Show the field ONLY if:
[hrp_complication_urine_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
195 |
[referred_urine_nine]
Show the field ONLY if:
[hrp_complication_urine_nine] = '1'
|
Referred
|
yesno, Required |
|
196 |
[usg_nine] |
USG checked |
yesno, Required |
|
197 |
[informed_abt_usg_nine]
Show the field ONLY if:
[usg_nine] = '1'
|
Were you informed about the result?
|
yesno, Required |
|
198 |
[hrp_complication_usg_nine]
Show the field ONLY if:
[usg_nine] = '1'
|
Was any HRP/complication identified based upon the test results?
|
yesno, Required |
|
199 |
[medicines_usg_nine]
Show the field ONLY if:
[hrp_complication_usg_nine] = '1'
|
Medicines/ treatment provided
|
yesno, Required |
|
200 |
[referred_usg_nine]
Show the field ONLY if:
[hrp_complication_usg_nine] = '1'
|
Referred
|
yesno, Required |
|
201 |
[danger_signs_nine] |
Danger Signs |
descriptive |
|
202 |
[did_you_experience_nine] |
"Did you experience any of the following danger signs anytime after the last interview?
(Multiple responses can be selected)"
|
checkbox, Required1 | did_you_experience_nine___1 | Vaginal Bleeding | 2 | did_you_experience_nine___2 | Severe Headaches | 3 | did_you_experience_nine___3 | Blurred Vision | 4 | did_you_experience_nine___4 | Reduced fetal movements | 5 | did_you_experience_nine___5 | Excessive swelling in face or hands or feet | 6 | did_you_experience_nine___6 | Convulsions | 7 | did_you_experience_nine___7 | Fever | 8 | did_you_experience_nine___8 | Severe Abdominal Pain | 9 | did_you_experience_nine___9 | Dizziness and Lightheadedness | 10 | did_you_experience_nine___10 | Fatigue and Weakness | 11 | did_you_experience_nine___11 | Fast or difficult Breathing/shortness of breath | 12 | did_you_experience_nine___12 | No | 13 | did_you_experience_nine___13 | Any other |
|
|
203 |
[any_other_specify_nine]
Show the field ONLY if:
[did_you_experience_nine(13)] = '1'
|
Any other, specify
|
text, Required |
|
204 |
[experia_any_danger_sig_nine]
Show the field ONLY if:
[did_you_experience_nine(1)] = '1' or [did_you_experience_nine(2)] = '1' or [did_you_experience_nine(3)] = '1' or [did_you_experience_nine(4)] = '1' or [did_you_experience_nine(5)] = '1' or [did_you_experience_nine(6)] = '1' or [did_you_experience_nine(6)] = '1' or [did_you_experience_nine(7)] = '1' or [did_you_experience_nine(8)] = '1' or [did_you_experience_nine(9)] = '1' or [did_you_experience_nine(10)] = '1' or [did_you_experience_nine(11)] = '1' or [did_you_experience_nine(13)] = '1'
|
Experienced any danger sign, how did you manage it?
|
radio, Required1 | At home | 2 | Visited government facility | 3 | Visited private facility | 4 | Consulted religious practitioners |
|
|
205 |
[nd_followup_form_9th_month_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|
|
206 |
[date_of_survey_fnl] |
Date of survey
|
text (date_dmy), Required |
|
207 |
[name_of_interviwer_final] |
Name of interviewer |
text, Required Field Annotation: @APPUSERNAME-APP |
|
208 |
[rch_id_final] |
RCH id |
text |
|
209 |
[phone_number_final] |
Phone Number of pregnant women 1 |
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
210 |
[phone_number_final_2] |
Phone Number of pregnant women 2 if second no is not available (9999999999)
|
text (number, Min: 3333333333, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
211 |
[maternal_outcome] |
Maternal outcome |
descriptive |
|
212 |
[mother_s_current_status] |
Mother's current status
|
radio, Required |
|
213 |
[relation_of_respondent]
Show the field ONLY if:
[mother_s_current_status] = '2'
|
Specify the relation of the respondent with the baby |
text, Required |
|
214 |
[fetal_outcome] |
Fetal outcome |
descriptive |
|
215 |
[delivery_date] |
What was the date of your delivery?
|
text (date_dmy), Required |
|
216 |
[type_of_facility_delivery] |
Type of facility where baby was delivered |
radio, Required1 | Public/government facility | 2 | Private facility | 3 | Semi/aided facility | 4 | Other |
|
|
217 |
[other_place_delivery]
Show the field ONLY if:
[type_of_facility_delivery] = '4'
|
Other |
text, Required |
|
218 |
[what_was_the_baby_s_sex] |
What was the baby's sex?
|
radio, Required |
|
219 |
[outcome_of_delivery] |
Outcome of Delivery
|
radio, Required |
|
220 |
[current_status]
Show the field ONLY if:
[outcome_of_delivery] = '1'
|
current Status? |
radio, Required |
|
221 |
[the_date_of_death]
Show the field ONLY if:
[current_status] = '2'
|
The date of death?
|
text (date_dmy), Required |
|
222 |
[appearance_of_baby]
Show the field ONLY if:
[outcome_of_delivery] = '2'
|
How was the appearance of the baby?
|
radio, Required1 | Fresh | 2 | Decomposed or macerated | 3 | Don't know |
|
|
223 |
[before_labour] |
Before labour |
descriptive, Required |
|
224 |
[labor_induced] |
Was the labor induced or augmented (any medicine given to increase pain?)
|
yesno, Required |
|
225 |
[put_a_pressure_abdomen] |
Did anyone put a pressure on your abdomen during labour?
|
yesno, Required |
|
226 |
[gestational_age_at_labour] |
Gestational age at the time of delivery
|
text (number), Required |
|
227 |
[gestational_age_at]
Show the field ONLY if:
[gestational_age_at_labour] < 34
|
Ask if Gestational age at the time of labor < 34 weeks, any injection given to stop the pain (Antenatal corticosteroid)?
|
yesno, Required |
|
228 |
[how_many_times_was_the_inj]
Show the field ONLY if:
[gestational_age_at] = '1'
|
How many times was the injection given?
|
radio, Required |
|
229 |
[specify_number_inje]
Show the field ONLY if:
[how_many_times_was_the_inj] = '1'
|
Specify number |
text (integer), Required |
|
230 |
[what_was_the_interval_betw]
Show the field ONLY if:
[gestational_age_at] = '1'
|
What was the interval between last dose of injection and delivery?
|
radio, Required |
|
231 |
[specify_in_minutes_or_hour]
Show the field ONLY if:
[what_was_the_interval_betw]='1'
|
Specify in minutes or hours |
text, Required |
|
232 |
[during_labour_and_delivery] |
During labour and delivery |
descriptive |
|
233 |
[where_was_the_baby_deliver] |
Where was the baby delivered?
|
radio, Required1 | Government Hospital | 2 | Private Hospital | 3 | Government-aided Hospital | 4 | On route to hospital | 5 | Home | 6 | Others |
|
|
234 |
[others_place_delivery]
Show the field ONLY if:
[where_was_the_baby_deliver] = '6'
|
Other |
text, Required |
|
235 |
[how_was_the_baby_delivered] |
How was the baby delivered?
|
radio, Required1 | Normal vaginal delivery | 2 | Assisted vaginal delivery | 3 | Cesarean section | 4 | Don't Know |
|
|
236 |
[did_you_encounter_any_of_t] |
Did you encounter any of the following problems during labour?
|
checkbox, Required1 | did_you_encounter_any_of_t___1 | Convulsions | 2 | did_you_encounter_any_of_t___2 | High blood pressure | 3 | did_you_encounter_any_of_t___3 | Fever | 4 | did_you_encounter_any_of_t___4 | Excessive bleeding | 5 | did_you_encounter_any_of_t___5 | Cord around the child's neck | 6 | did_you_encounter_any_of_t___6 | Others | 7 | did_you_encounter_any_of_t___7 | No |
|
|
237 |
[other_prblm_during_del]
Show the field ONLY if:
[did_you_encounter_any_of_t] = '6'
|
Other |
text, Required |
|
238 |
[after_delivery_form_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
|