DEMOGRAPHIC AND HEALTH SURVEYS
NON-COMMUNICABLE DISEASES MODULE
MODEL MAN'S QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF MAN __________
(1) This section should be adapted for country-specific survey design.
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:
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
SECTION ND: NON-COMMUNICABLE DISEASES FOR MAN'S QUESTIONNAIRE
ND01) Have you ever had your blood pressure measured by a doctor or other health worker?
NO 2
DON'T KNOW 8
ND02) Have you ever been told by a doctor or other health worker that you have high blood pressure or hypertension?
NO 2 (GO TO ND06)
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?
NO 2
ND04) Has a doctor or other healthcare worker prescribed medication to control your blood pressure?
NO 2
ND05) Are you taking medication to control your blood pressure?
NO 2
ND06) Have you ever had your blood sugar measured by a doctor or other health worker?
NO 2
DON'T KNOW 8
ND07) Have you ever been told by a doctor or other health worker that you have high blood sugar or diabetes?
NO 2 (GO TO ND11)
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?
NO 2
ND09) Has a doctor or other healthcare worker prescribed medication to control your high blood sugar or diabetes?
NO 2
ND10) Are you taking medication to control your high blood sugar or diabetes?
NO 2
ND11) Have you ever been told by a doctor or other health worker that you have heart disease or a chronic heart condition?
NO 2 (GO TO ND13)
ND12) Are you receiving any treatment for your heart disease or chronic heart condition?
NO 2
ND13) Have you ever been told by a doctor or other health worker that you have lung disease or a chronic lung condition?
NO 2 (GO TO ND15)
ND14) Are you receiving any treatment for your lung disease or chronic lung condition?
NO 2
ND15) Have you ever been told by a doctor or other health worker that you have cancer or a tumor?
NO 2 (GO TO ND17)
ND16) Are you receiving any treatment for cancer or a tumor?
NO 2
ND17) Have you ever been told by a doctor or other health worker that you have depression?
NO 2 (GO TO ND19)
ND18) Are you receiving any treatment for depression?
NO 2
ND19) Have you ever been told by a doctor or other health worker that you have arthritis?
NO 2 (GO TO ND21)
ND20) Are you receiving any treatment for arthritis?
NO 2
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?
NO 2 (GO TO ND23)
ND22) Are you receiving any treatment for (CHRONIC DISEASE FROM ND21)?
NO 2