IDENTIFICATION (1)

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________

(1) This section should be adapted for country-specific survey design.

INTERVIEWER VISITS

FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __

TOTAL NUMBER OF VISITS: __

*RESULT CODES:

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES

SUPERVISOR
NAME ______
NUMBER __ __ __ __

FIELD EDITOR
NAME ______
NUMBER __ __ __ __

OFFICE EDITOR
NUMBER __ __

KEYED BY
NUMBER __ __

SECTION ND: NON-COMMUNICABLE DISEASES FOR WOMAN'S QUESTIONNAIRE

ND01) Have you ever had your blood pressure measured by a doctor or other health worker?

ND02) Have you ever been told by a doctor or other health worker that you have high blood pressure or hypertension?

ND03) In the past 12 months, have you been told by a doctor or other health worker than you have high blood pressure or hypertension?

ND04) Has a doctor or other healthcare worker prescribed medication to control your blood pressure?

ND05) Are you taking medication to control your blood pressure?

ND06) Have you ever had your blood sugar measured by a doctor or other health worker?

ND07) Have you ever been told by a doctor or other health worker that you have high blood sugar or diabetes?

ND08) In the past 12 months, have you been told by a doctor or other health worker than you have high blood sugar or diabetes?

ND09) Has a doctor or other healthcare worker prescribed medication to control your high blood sugar or diabetes?

ND10) Are you taking medication to control your high blood sugar or diabetes?

ND11) Have you ever been told by a doctor or other health worker that you have heart disease or a chronic heart condition?

ND12) Are you receiving any treatment for your heart disease or chronic heart condition?

ND13) Have you ever been told by a doctor or other health worker that you have lung disease or a chronic lung condition?

ND14) Are you receiving any treatment for your lung disease or chronic lung condition?

ND15) Have you ever been told by a doctor or other health worker that you have cancer or a tumor?

ND16) Are you receiving any treatment for cancer or a tumor?

ND17) Have you ever been told by a doctor or other health worker that you have depression?

ND18) Are you receiving any treatment for depression?

ND19) Have you ever been told by a doctor or other health worker that you have arthritis?

ND20) Are you receiving any treatment for arthritis?

ND21) Have you ever been told by a doctor or other health worker that you have any other chronic disease, that is, any other disease that is long lasting?

ND22) Are you receiving any treatment for (CHRONIC DISEASE FROM ND21)?

ND23) Have you heard of cervical cancer?

ND24) Have you heard of any test for cervical cancer?

ND25) Now I'm going to ask you about tests a health care worker can do to check for cervical cancer, which is cancer in the cervix. The cervix connects the womb to the vagina. To be checked for cervical cancer, a woman is asked to lie on her back with her legs apart. Then the health care worker will use a brush or swab to collect a sample from inside her. The sample is sent to a laboratory for testing. This test is called a Pap smear or HPV test. Another method is called a VIA or Visual Inspection with Acetic Acid. In this test, the health care worker puts vinegar on the cervix to see if there is a reaction.

ND26) Has a doctor or other healthcare worker ever tested you for cervical cancer?

ND27) When was your last test for cervical cancer? IF LESS THAN 1 YEAR, RECORD '00'.

ND28) What was the result of your last test for cervical cancer?

ND29) Did you receive any treatment to your cervix or have any follow up visits because of your test results?