Surveilance breasfeeding/morbidity form

Evaluation of breast feeding status (code: Yes=1, No=2, NA=9)

CHSUNO

CHSUNO

BF_M_1

Date

BF_M_1

BF_M_2

Visit number

BF_M_2

BF_M_3

FW code

lkmN8 sfo{stf{ ;+s]t

BF_M_3

BF_M_4

Is the child breastfed?

BF_M_4

If yes, number of breast feeding in last 24 hours

BF_M_4_d

daytime

BF_M_4_d

BF_M_4_n

nigthtime

BF_M_4_n

BF_M_5

Does the child consume semi-solid or solid food? Specify                                                            s] aRrfn] 7f];–cw{7f]; vfg]s'/f vfG5 < pNn]v ug'{xf];\

BF_M_5

BF_M_6

Does the child consume other milk? Specify                                                                                    s] aRrfn] cfdfsf] b'w jfx]s c? b'w klg lkp“5 < pNn]v ug'{xf];

BF_M_6

BF_M_7

Does the child consume any other liquids?                                                                                                            s] aRrfn] cfdfsf] b'w jfx]s c? emf]n kbfy{ klg lkp“5 <

BF_M_7

BF_M_7_1

Water?  kfgL lkp“5 <

BF_M_7_1

BF_M_7_2

Ghutti?  3'§L lbg' ePsf] 5 <

BF_M_7_2

BF_M_7_3

Fruit juices, specify -kmnkm"nsf /;x¿, pNn]v ug'{xf];_

BF_M_7_3

BF_M_7_4

Others, specify -cGo, pNn]v ug'{xf];_

BF_M_7_4

BF_M_7_5

Others, specify -cGo, pNn]v ug'{xf];_

BF_M_7_5

MORBIDITY (during last month)

BF_M_8

Did the child have loose watery motions three or more times in a day? -slt k6s ef8fkvfnf nfu]sf] 5<_

BF_M_8

BF_M_9

Cough and difficulty breathing -slt k6s Go"df]lgof ePsf] 5<_

BF_M_9

BF_M_10

Pneumonia (1= yes, 2= no, cough and cold only, 9= not applicable)

BF_M_10

BF_M_11

Fever (1=yes, 2= no)

BF_M_11

BF_M_12

Did you visit a heatlh center because child was ill (1=yes, 2=no)

BF_M_12

BF_M_13

hopitalization -c:ktfndf egf{ ePsf] 5<_

BF_M_13

BF_M_13_1

Specify, reason for hospitalization -c:ktfndf e\gf{ ePsf] sf/0f pNn]v ug'{xf];_

BF_M_13_1