Form 1
Variable Name Field Label Identifier?
record_id
Record ID
rch_id
1.1 RCH-ID / MCP card
receive_date
Date when received
other_district_name
Other district name
other_taluka_name
Other taluka name
name_of_the_asha
1.1.3 Name of the ASHA
name_of_the_mother
1.2 Name of the mother
age_mother
Age of the mother
name_of_the_spouse
1.3 Name of the husband
present_address
1.9 Present Address House Number and Street :
{house_number_and_street} City / Town / Village name:
{city_town_village_name} District: {district_address} Pin Code : {pin_code}
house_number_and_street
House Number and Street
city_town_village_name
City / Town / Village Name
district_address
District
other_district_name_1
Other district name
present_same_address
1.9.a Is the present address same as the permanent address?
permant_addr_2
Permanent address : [house_number_and_street]
[city_town_village_name] [district_address] [pin_code]
permanant_address
1.10 Permanent Address House Number and Street :
{house_number_and_street_2} City / Town / Village
name : {city_town_village_name_2} District :
{district_address_2} Pin Code : {pin_code_2}
house_number_and_street_2
House Number and Street
city_town_village_name_2
City / Town / Village Name
district_address_2
District
gravida
Section Header: Section 2 : Obstetric Details2.1 Gravida (number of pregnancies a woman had)
mnth_occur
2.4.a Which month did the first abortion occur?
scnd_abort
2.4.b Which month did the second abortion occur?
stllbrth_1
2.5.a Which month did the first stillbirth occur?
stllbrth_2
2.5.b Which month did the second stillbirth occur?
neonatal_deaths
2.6 a. Which day of life did first neonatal death occur?
neontl_dths
2.6.c Which day of life did second neonatal death occur?
lmp
2.7.2 LMP
edd
2.7.3 EDD
another_smoke_inside_home
3.4 Another household member who smokes inside the
house
contracep_3
3.6 Did you use any contraception
(pills/natural/condom/IUCD) before pregnancy?
special_medication
Medication Prescribed If YES - medication was
prescribed, then did you take the medication If yes,
details 3.8.1 High dose Folic acid (0.5g per day)
{sm_high_dose_flic_acd_prec} {sm_took_medication}
How many tablets were bought/given?
{sp_fa_tablets_bought} How many tablets were
consumed? {sp_fa_tablets_consumed} 3.8.2 Weekly Iron
Supplementation {sm_iron_prescribed}
{sm_took_iron_medication} How many tablets were
bought/given? {sm_iron_tab_bought} How many tablets
were consumed? {sm_iron_tab_consumed}
sm_high_dose_flic_acd_prec
3.8.1 High dose Folic acid (0.5g per day) prescribed
sm_took_medication
Medication was prescribed, then did you take the medication (folic acid)
sm_took_iron_medication
Medication was prescribed, then did you take the medication (Iron)
yes_howmny_anc
How many ANC visits did you have for this pregnancy?
why_no_anc
Why did you not go for any ANC?
obtained_previous_pregn_ancy_history_and_recorde_d
4.2 Was previous pregnancy history obtained andrecorded?[If Primi mothers choose not applicable]
medical_problem_prev_pr_eg
4.3 Has been diagnosed with any medical problem before the present pregnancy?
specify_medical_prob_pr_ev_preg
4.3.1 IF YES, Specify medical problem during the previous pregnancy
other_medical_prob_prev_preg
Specify
date_anc_visits_a1
Date of 1st ANC visit
gestational_ages_a1
Gestational age at 1st ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_1
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_1
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_1
Record of fetal lie in ANC visit 1
rcrd_symp_1
Record symphysis fundal height (SFH) at the 1st ANC visit
rcrd_fhr_1
Record FHR [>22wks] at 1st Visit
tft_1
Thyroid profile at 1st Visit
aobt_results_a1
Record any other test results at the 1st ANC visit, if available
urine_albumin_results_a1
Record Urine Albumin test results at 1st ANC visit, if available
urine_sugar_test_results_a1
Record urine sugar test results at 1st ANC visit, if available
urine_microscopy_results_a1
Record urine microscopy results at 1st ANC visit, if available
usg_a1
Did ultrasonography on the 1st ANC visit?
usgda_a1
Date of ultrasonography at 1st ANC visit
date_nst_ctg_anc_1
Date NST / CTG done ANC visit 1
doppler_date_a1
Date of Doppler at 1st ANC visit
oth_investigation_test_name_a1
Name of any other radiological test done at the 1st ANC visit
oth_investigation_test_date_a1
Date of the Radiological test at the 1st ANC visit
date_anc_visits_a2
Date of 2nd ANC visit
gestational_ages_a2
Gestational age at 2nd ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_2
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_2
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_2
Record of fetal lie in ANC visit 2
rcrd_symp_2
Record symphysis fundal height (SFH) at the 2nd ANC visit
rcrd_fhr_2
Record FHR [>22wks] at 2nd Visit
tft_2
Thyroid profile at 2nd Visit
aobt_results_a2
Record any other test results at the 2nd ANC visit, if available
urine_albumin_results_a2
Record Urine Albumin test results at 2nd ANC visit, if available
urine_sugar_test_results_a2
Record urine sugar test results at 2nd ANC visit, if available
urine_microscopy_results_a2
Record urine microscopy results at 2nd ANC visit, if available
usg_a2
Did ultrasonography on the 2nd ANC visit?
usgda_a2
Date of ultrasonography at 2nd ANC visit
date_nst_ctg_anc_2
Date NST / CTG done ANC visit 2
doppler_date_a2
Date of Doppler at 2nd ANC visit
oth_investigation_test_name_a2
Name of any other radiological test done at the 2nd ANC visit
oth_investigation_test_date_a2
Date of the Radiological test at the 2nd ANC visit
date_anc_visits_a3
Date of 3rd ANC visit
gestational_ages_a3
Gestational age at 3rd ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_3
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_3
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_3
Record of fetal lie in ANC visit 3
rcrd_symp_3
Record symphysis fundal height (SFH) at the 3rd ANC visit
rcrd_fhr_3
Record FHR [>22wks] at 3rd Visit
tft_3
Thyroid profile at 3rd Visit
aobt_results_a3
Record any other test results at the 3rd ANC visit, if available
urine_albumin_results_a3
Record Urine Albumin test results at 3rd ANC visit, if available
urine_sugar_test_results_a3
Record urine sugar test results at 3rd ANC visit, if available
urine_microscopy_results_a3
Record urine microscopy results at 3rd ANC visit, if available
usg_a3
Did ultrasonography on the 3rd ANC visit?
usgda_a3
Date of ultrasonography at 3rd ANC visit
date_nst_ctg_anc_3
Date NST / CTG done ANC visit 3
doppler_date_a3
Date of Doppler at 3rd ANC visit
oth_investigation_test_name_a3
Name of any other radiological test done at the 3rd ANC visit
oth_investigation_test_date_a3
Date of the Radiological test at the 3rd ANC visit
date_anc_visits_a4
Date of 4th ANC visit
gestational_ages_a4
Gestational age at 4th ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_4
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_4
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_4
Record of fetal lie in ANC visit 4
rcrd_symp_4
Record symphysis fundal height (SFH) at the 4th ANC visit
rcrd_fhr_4
Record FHR [>22wks] at 4th Visit
tft_4
Thyroid profile at 4th Visit
aobt_results_a4
Record any other test results at the 4th ANC visit, if available
urine_albumin_results_a4
Record Urine Albumin test results at 4th ANC visit, if available
urine_sugar_test_results_a4
Record urine sugar test results at 4th ANC visit, if available
urine_microscopy_results_a4
Record urine microscopy results at 4th ANC visit, if available
usg_a4
Did ultrasonography on the 4th ANC visit?
usgda_a4
Date of ultrasonography at 4th ANC visit
date_nst_ctg_anc_4
Date NST / CTG done ANC visit 4
doppler_date_a4
Date of Doppler at 4th ANC visit
oth_investigation_test_name_a4
Name of any other radiological test done at the 4th ANC visit
oth_investigation_test_date_a4
Date of the Radiological test at the 4th ANC visit
date_anc_visits_a5
Date of 5th ANC visit
gestational_ages_a5
Gestational age at 5th ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_5
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_5
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_5
Record of fetal lie in ANC visit 5
rcrd_symp_5
Record symphysis fundal height (SFH) at the 5th ANC visit
rcrd_fhr_5
Record FHR [>22wks] at 5th Visit
tft_5
Thyroid profile at 5th Visit
aobt_results_a5
Record any other test results at the 5th ANC visit, if available
urine_albumin_results_a5
Record Urine Albumin test results at 5th ANC visit, if available
urine_sugar_test_results_a5
Record urine sugar test results at 5th ANC visit, if available
urine_microscopy_results_a5
Record urine microscopy results at 5th ANC visit, if available
usg_a5
Did ultrasonography on the 5th ANC visit?
usgda_a5
Date of ultrasonography at 5th ANC visit
date_nst_ctg_anc_5
Date NST / CTG done ANC visit 5
doppler_date_a5
Date of Doppler at 5th ANC visit
oth_investigation_test_name_a5
Name of any other radiological test done at the 5th ANC visit
oth_investigation_test_date_a5
Date of the Radiological test at the 5th ANC visit
date_anc_visits_a6
Date of 6th ANC visit
gestational_ages_a6
Gestational age at 6th ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_6
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_6
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_6
Record of fetal lie in ANC visit 6
rcrd_symp_6
Record symphysis fundal height (SFH) at the 6th ANC visit
rcrd_fhr_6
Record FHR [>22wks] at 6th Visit
tft_6
Thyroid profile at 6th Visit
aobt_results_a7
Record any other test results at the 6th ANC visit, if available
urine_albumin_results_a6
Record Urine Albumin test results at 6th ANC visit, if available
urine_sugar_test_results_a6
Record urine sugar test results at 6th ANC visit, if available
urine_microscopy_results_a6
Record urine microscopy results at 6th ANC visit, if available
usg_a6
Did ultrasonography on the 6th ANC visit?
usgda_a6
Date of ultrasonography at 6th ANC visit
date_nst_ctg_anc_6
Date NST / CTG done ANC visit 6
doppler_date_a6
Date of Doppler at 6th ANC visit
oth_investigation_test_name_a6
Name of any other radiological test done at the 6th ANC visit
oth_investigation_test_date_a6
Date of the Radiological test at the 6th ANC visit
date_anc_visits_a7
Date of 7th ANC visit
gestational_ages_a7
Gestational age at 7th ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_7
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_7
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_7
Record of fetal lie in ANC visit 7
rcrd_symp_7
Record symphysis fundal height (SFH) at the 7th ANC visit
rcrd_fhr_7
Record FHR [>22wks] at 7th Visit
tft_7
Thyroid profile at 7th Visit
aobt_results_a6
Record any other test results at the 6th ANC visit, if available
urine_albumin_results_a7
Record Urine Albumin test results at 7th ANC visit, if available
urine_sugar_test_results_a7
Record urine sugar test results at 7th ANC visit, if available
urine_microscopy_results_a7
Record urine microscopy results at 7th ANC visit, if available
usg_a7
Did ultrasonography on the 7th ANC visit?
usgda_a7
Date of ultrasonography at 7th ANC visit
date_nst_ctg_anc_7
Date NST / CTG done ANC visit 7
doppler_date_a7
Date of Doppler at 7th ANC visit
oth_investigation_test_name_a7
Name of any other radiological test done at the 7th ANC visit
oth_investigation_test_date_a7
Date of the Radiological test at the 7th ANC visit
date_anc_visits_a8
Date of 8th ANC visit
gestational_ages_a8
Gestational age at 8th ANC visit(in weeks)
increased_frequency_burning_while_passng_urin_anc_8
Increased frequency / burning while passing urine
breathlessness_tirednes_anc_8
Any breathlessness / tiredness
rcord_of_fetal_lie_anc_8
Record of fetal lie in ANC visit 8
rcrd_symp_8
Record symphysis fundal height (SFH) at the 8th ANC visit
rcrd_fhr_8
Record FHR [>22wks] at 8th Visit
aobt_results_a8
Record any other test results at the 8th ANC visit, if available
urine_albumin_results_a8
Record Urine Albumin test results at 8th ANC visit, if
available
urine_sugar_test_results_a8
Record urine sugar test results at 8th ANC visit, if available
urine_microscopy_results_a8
Record urine microscopy results at 8th ANC visit, if available
usg_a8
Did ultrasonography on the 8th ANC visit?
usgda_a8
Date of ultrasonography at 8th ANC visit
date_nst_ctg_anc_8
Date NST / CTG done ANC visit 8
doppler_date_a8
Date of Doppler at 8th ANC visit
oth_investigation_test_name_a8
Name of any other radiological test done at the 8th ANC
visit
oth_investigation_test_date_a8
Date of the Radiological test at the 8th ANC visit
prescribe_folic_acid_iron
5.1.1. Iron & Folic acid(only in 1st trimester)
took_iron_folic_acid
Took the medication (Iron & Folic acid)
folic_acid_details
How many tablets were bought/given
pih_hyp_names
Name
date_1st_tt
Date of 1st dose
date_2nd_tt
Date of 2nd dose
date_of_booster_dose
Date of Booster Dose (if no of pregnancy second / third / ect. )
date_inj_iron
Date
date_antibiotics
Date
name_diab_medication
Name
thyroid_medication_prescribed
5.1.9 Thyroid supplement
took_thyroid_medication
Then specify if you took the medication
name_thyroid_medication
Name
details_thyroid_medication
Details
name_oth_medication
Name
oth_inj_name
Name
counseling_information_given
Check if any counseling/information was given and recorded during ANC visit Source (MCP/report/ CI)
sleep_side_right_or_left
b. Sleep on a side (right or left side)
when_admitted_during_preg
5.3.2 When was she admitted
same_health_facility
5.3.5 Did she go to the same health facility?[If admitted once, choose not applicable]
no_where
5.3.6 Where did she go? and why?
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