M_1 |
Initials of the child |
M _2 |
Researcher code |
M _3 |
Date of Interview |
M _4 |
Why did the caregiver seek
health care for the child (1=Diarrhoea/vomiting, 2=Cough /cold/sore throat,
3= Fever, 4= ENT problem, 5= Feeding problems, 6= Skin problem, 7=Eye, 8=
Other, specify) |
M _4txt |
If other, specify |
M _5 |
Did the child seek out medical
care as a result of the illness before? (1= Yes, 2=No) |
M _6 |
Was any medicine given the
child for the illness? (2=No, 3=
Symptomatic, 4= Antibiotic, 5=vitamins/minerals, 6= Others |
M _6txt |
If other, specify |
M _7 |
Clinical Diagnosis 1 (1=AGE, 2=
AGE with dehydration, 3=Bacterial dysentery,4=URTI, 5= ALRI, 6= RAD, 7=Otitis
Media, 8= Anemia, 9= Malnutrition, 10=Skin allergic rash, 11=Pyoderma, 12=
Fever 13= Eye infection, 14=Others |
M _7txt |
If other, specify |
M _8 |
Hospitalization?( 2 = No, 3=
Severe pneumonia, 4=AGE with dehydration, 5=High grade fever under
investigations, 6=Fever with convulsion, 7=Severe PEM, 8=UTI, 9= Meningitis,
10=Other)( 2 = No, 3= Severe pneumonia, 4=AGE with dehydration, 5=High grade
fever under investigations, 6=Fever with convulsion, 7=Severe PEM, 8=UTI, 9=
Meningitis, 10=Other) |
M _8txt |
If other, specify |
M _9 |
Referred to other Health
Facility? |
M _9txt |
If Yes, reason? |
M_10 |
Medication given (2=No, 3=
Symptomatic, 4= Antibiotics, 5= Anti-convulsant, 6= Local medicine,7=Other) |
M_10txt |
If Antibiotic, which group? |
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