Morbidity Form
	Sep-07
	Use (1 for yes, 2 for no and 9 for not applicable if no other options)
CHSUNO	Child survey number	CHSUNO
Chsno	Child serial number (for mother, add 10,000 to her child's chsno)	Chsno
BF2_2	Date	BF2_2
BF2_3	Doctor code	BF2_3
BF2_4	Age (years)	BF2_4
	Past medical history
BF2_5	Gravida	BF2_5
BF2_6	Paria	BF2_6
BF2_7	Has the women received a large dose vitamin A in the past 4 months	BF2_7
BF2_8	Did the woman take any nutrient supplement during pregnancy, indicate start trimester and duration in months		Start trim			Duration  (month)
	Iron	BF2_8i_s					BF2_8i_d
	Calcium	BF2_8c_s					BF2_8c_d
	Folate	BF2_8f_s					BF2_8f_d
BF2_9	Does the woman take vitamin or mineral supplements regularly	BF2_9
	If yes, what is she taking
	Recent medical history (last 4  weeks)
BF2_10	Days with fever	BF2_10
BF2_11	Days with diarrhea	BF2_11
BF2_12	Days with pneumonia	BF2_12
BF2_13	Has the women visited a physician for any of these illnesses (yes=1, no=2)	BF2_13
BF2_14	Has the women been hosptializedfor any of these illnesses (yes=1, no=2)	BF2_14
BF2_15	Does the women/spouse use any kind of contraception (2 = no, 3 = condom, 4 =
	progesterone injection, 5 = pills, 6 = T-coil,
	7 = she or husband has gone through operation, 9 = not applicable)
BF2_15_n	Now	BF2_15_n
BF2_15_p	Previously	BF2_15_p
BF2_15_d	If depoprovera or pills, duration of use before pregnant (years)	BF2_15_d
BF2_16	Any ongoing infectious diseases (2= no, 3= diarrhea, 4 = cough, 5 = fever,	BF2_16
	6 = skin infection, 7 = common cold, 8 = other)
BF2_17	Weight (kgs)	BF2_17
BF2_18	Length (cms)	BF2_18
BF2_19_s	Blood pressure  systolic	BF2_19_s
BF2_19_d	blood pressure  diastolic	BF2_19_d
BF2_20	Temperature (F) (if reported fever)	BF2_20			.
	SUPERVISOR'S SIGNATURE
	DATA ENTRY 1
	DATA ENTRY 2