(Form B2)
No. _____
Date of interview: |
Date of check: |
Name of interviewer: |
Name of Team Leader: |
Signature: |
Signature: |
1. Subdistrict: |
_______________________ |
| |
|
2. Village: |
_______________________ |
| |
|
3. R.T/R.W: |
_______________________ |
4. Health facility:
1. Health centre
2. Sub health centre
3. Doctor in private practice
4. Nurse in private practice
5. Midwife in private practice
6. Health cadre
7. Traditional practitioner
5. Name of respondent: |
___________________ |
6. Who is the patient:
1. Respondent
2. Attendant _________________ (explain)
7. Can I see your treatment card?
Note down: |
Name: ____________________ |
Age:________________ |
Address:__________________ Sex: |
____________________ |
Other information: |
No. of card: |
____________________ |
| |
Disease: |
____________________ |
| |
Complaint: |
____________________ |
8. What is the complaint?
1. Fever
2. Cough/cold/flu
3. Abdominal pains/diarrhea
4. Weakness/muscle pains
5. Skin disease
6. Others, explain:_______________________
9. According to the health worker, what is your disease:
___________________________________________________
___________________________________________________
10. Did you get an injection?
1. Yes
2. No ___________>stop
11. Who gives the injection?
1. Doctor (in governmental facility)
2. Nurse/midwife (in governmental facility)
3. Doctor in private practice
4. Nurse in private practice
5. Midwife in private practice
6. Traditional practitioner, explain: ___________________
12 Is this injection given on your request?
1. Yes
2. No
13. Why do you like injections?
1. Faster cure
2. Cheap
3. Habit/custom
4. Often forget to take medicine
5. Others, explain:_______________________________