| Variables in Self Reporting Questionnaire (SRQ) | |||||
| Question# | Question | Field name | Response nature | Response options | |
| 1 | PID Number | PID | ### | ||
| 2 | SRQ Number | SRQ no | # | ||
| 2 | Initials of the participant/mother | Srq_A | XX | ||
| 3 | Researcher Code | Srq_B | ## | ||
| 4 | Date
of interview (According to English calender) |
Srq _C | ##-XXX-## | dd-mmm-yy | |
| 5 | Age of the child (months) | Srq _D | ## | 99
if SRQ is being done during pregnancy ## if SRQ is being done after delivery |
|
| Ask for the last one month (1= Yes, 0= No) | |||||
| 6 | Do you often have headaches? | Srq _1 | # | 1=Yes, 0=No | |
| 7 | Is your appetite poor? | Srq _2 | # | 1=Yes, 0=No | |
| 8 | Do you sleep badly? | Srq _3 | # | 1=Yes, 0=No | |
| 9 | Are you easily frightened? | Srq _4 | # | 1=Yes, 0=No | |
| 10 | Do your hands shake? | Srq _5 | # | 1=Yes, 0=No | |
| 11 | Do you feel nervous, tense or worried? | Srq _6 | # | 1=Yes, 0=No | |
| 12 | Is your digestion poor? | Srq _7 | # | 1=Yes, 0=No | |
| 13 | Do you have trouble thinking clearly? | Srq _8 | # | 1=Yes, 0=No | |
| 14 | Do you feel unhappy? | Srq _9 | # | 1=Yes, 0=No | |
| 15 | Do you cry more than usual? | Srq _10 | # | 1=Yes, 0=No | |
| 16 | Do you find it difficult to enjoy your daily activities? | Srq _11 | # | 1=Yes, 0=No | |
| 17 | Do you find it difficult to make decisions? | Srq _12 | # | 1=Yes, 0=No | |
| 18 | Is your daily work suffering? | Srq _13 | # | 1=Yes, 0=No | |
| 19 | Are you unable to play a useful part in life? | Srq _14 | # | 1=Yes, 0=No | |
| 20 | Have you lost interest in things? | Srq _15 | # | 1=Yes, 0=No | |
| 21 | Do you feel that you are a worthless person? | Srq _16 | # | 1=Yes, 0=No | |
| 22 | Has the thought of ending your life been on your mind? | Srq _17 | # | 1=Yes, 0=No | |
| 23 | Do you feel tired all the time? | Srq _18 | # | 1=Yes, 0=No | |
| 24 | Do you have uncomfortable feelings in your stomach? | Srq _19 | # | 1=Yes, 0=No | |
| 25 | Are you easily tired? | Srq _20 | # | 1=Yes, 0=No | |
| 26 | Total | Srq _total | ## | Sum of scores of all items | |
| 27 | Remarks | TXT | |||