| Variables in PREGNANT MOTHER'S EXAMINATION FORM (PME) | ||||
| Question# | Question | Field name (Variable) | Response nature | Response options |
| 1 | PID Number | PID | ### | ### |
| 2 | Initials of the pregnant mother’s name | pme_A | XX | XX |
| 3 | Researcher code (Gynecologist) | pme _B | ## | ## |
| 4 | Date
of Interview (according to English calender) |
pme _C | ##-XXX-## | dd-mmm-yy |
| 5 | Age
of mother (completed years) |
pme _1 | ## | |
| 6 | Weight (kg) | pme _2 | ##.## | |
| 7 | Height (cm) | pme _3 | ###.# | |
| 8 | MUAC (cm) | pme _4 | ##.# | |
| 9 | Blood pressure: systolic/diastolic (mmHg) | pme _5 | ##/## | |
| 10 | Last
menstruation period (LMP) (according to English calender) |
pme _6 | ##-XXX-## | dd-mmm-yy (99/999/99 if not known) |
| 11 | Estimated
date of delivery (EDD) (according to English calender) |
pme _7 | ##-XXX-## | dd-mmm-yy (99/999/99 if not known) |
| 12 | Gestational age by LMP (weeks) | pme_8 | ## | |
| 13 | Number of gravida | pme _9 | ## | |
| 14 | Number of para | pme _10 | ## | |
| 15 | Number of abortion | pme _11 | ## | |
| 16 | Number of still birth | pme _12 | ## | |
| 17 | Number of death of baby | pme _13 | ## | |
| 18 | High risk for pregnancy by obstetric history ? | Pme_14 | # | 1=Yes, 2=No |
| 19 | Any complains by mother? | Pme_15 | # | 2=No,
3= nausea/vomiting, 4=appetite loss, 5= lower abdomen pain,
6=dizziness/vertigo, 7= PV bleeding, 8= others |
| 20 | If other specify | pme_15 txt | TXT | TEXT
if pme_15=8 NA if pme_15ǂ8 |
| Examination: | ||||
| 21 | CVS auscultation? | pme_16 | # | 1= Normal findings, 2= Abnormal findings |
| 22 | Chest auscultation? | pme_17 | # | 1= Normal findings, 2= Abnormal findings |
| 23 | Size of uterus by palpation (weeks) | pme_18 | ## | |
| 24 | Adnexal palpable | pme_19 | # | 1=Yes, 2=No |
| 25 | Position | pme_20 | # | 1= Axial, 2=Antroverted, 3=Retroverted, 4= Other |
| 26 | Any other abnormal findings or high risk for pregnancy by examination? | pme_21 | # | 1=Yes, 2=No |
| 27 | If abnormal findings , specify | pme_21txt | TXT | TEXT
if pme_21= 1 NA if pme_21=2 |
| Ask whether pregnant mother is taking any micronutrient/nutrient supplement currently: (1=Yes, 2=No) If any following answer will yes, write weeks of gestation when start to take the medicine, if not write 99. | ||||
| 28 | Folic acid? | pme_22 | # | 1=Yes, 2=No |
| 29 | If yes, when started? (weeks of gestation) | pme_22 txt | ## | ##
if pme_22=1 99 if pme_22=2 |
| 30 | Iron? | pme_23 | # | 1=Yes, 2=No |
| 31 | If yes, when started? (weeks of gestation) | pme_23 txt | ## | ##
if pme_23=1 99 if pme_23=2 |
| 32 | Calcium? | pme_24 | # | 1=Yes, 2=No |
| 33 | If yes, when started? (weeks of gestation) | pme_24 txt | ## | ##
if pme_24=1 99 if pme_24=2 |
| 34 | Any other vitamins or nutrient supplement? | pme_25 | # | 1=Yes, 2=No |
| 35 | If yes specify | pme_25 txt | TXT | TEXT
if pme_25=1 NA if pme_25=2 |
| 36 | Any other medication? | pme_26 | # | 1=Yes, 2=No |
| 37 | If yes specify | pme_26 txt | TXT | TEXT
if pme_26=1 NA if pme_26=2 |
| 38 | Remarks | TXT | ||