NAME AND CODE OF DISTRICT
NAME AND CODE OF VILLAGE/MUNICIPALITY
WARD NUMBER
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
ALTITUDE (METERS)
FIRST VISIT
DATE __
FIELD WORKER'S NAME___
NEXT VISIT:
DATE__
TIME__
SECOND VISIT
DATE__
FIELD WORKER'S NAME
NEXT VISIT:
DATE__
TIME__
THIRD VISIT
DATE__
FIELD WORKER'S NAME
FINAL VISIT
DAY __
MONTH__
YEAR__
TOTAL NUMBER OF VISITS
TOTAL ELGIBLE WOMEN
TOTAL ELGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LANGUAGE OF INTERVIEW
NEPALI 02
MAITHILI 03
BHOJPURI 04
OTHER 05
NATIVE LANGUAGE OF RESPONDENT
NEPALI 02
MAITHILI 03
BHOJPURI 04
OTHER 05
TRANSLATOR
NO 2
NUMBER__
OFFICE EDITOR
KEYED BY
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
101. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.
NAME___
103. IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM PREGNANCY HISTORY. IF MOTHER NOT INTERVIEWED ASK: What is (NAME)'s date of birth?
MONTH__
YEAR___
104. CHECK 103: CHILD BORN IN 2068-2073?
NO 2 (SKIP TO 114)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
107. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E, WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
110. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
(RECORD '00' IF NOT LISTED)
111. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. We ask that all children born in 2068 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team. Do you have any questions? You can say yes or no. It is up to you to decide. Will you allow (NAME OF CHILD) to participate in the anemia test?
112. CIRCLE THE CODE AND SIGN YOUR NAME
REFUSED 2 SIGN ___
NOT PRESENT/OTHER 3 (SKIP TO 114)
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA.
REFUSED 995
OTHER 996
114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15 AND ABOVE
201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9. NAME FROM FORM.
NAME___
203. CHECK HOUSEHOLD QUESTIONNAIRE
18-49 YEARS 2
50 YEARS AND ABOVE 3
204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8
OTHER 2
NOT PRESENT 99994 (GO TO 203 FOR NEXT WOMAN OR, IF NO MORE WOMEN GO TO 303)
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURER: ENTER YOUR FIELDWORKER NUMBER
18-49 YEARS 2 (SKIP TO 213)
50 AND ABOVE 3 (SKIP TO 213)
209. CHECK 204: MARITAL STATUS
OTHER 2 (SKIP TO 213)
210. PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT
210. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
(RECORD '00' IF NOT LISTED)
211. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 210 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)'s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)'s blood pressure?
212. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGN___ (SKIP TO 249)
ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
213. ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.
I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart.
The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow me to measure your blood pressure?
214. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 ___ (SKIP TO 243)
215. Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:
Eaten anything?
A) Had coffee, tea, cola or other drink that has caffeine?
B) Smoked or used any tobacco
C) product?
D) Took alcohol?
NO 2
NO 2
NO 2
NO 2
216. May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.
MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETRES.
217. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.
UNIVERSAL: 22 CM -42 CM 2
LARGE: 36 CM -45 CM 3
218. RECORD TIME OF FIRST BP READING
MINUTES___
219. TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 243)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 243)
OTHER 996 (IF NOT MEASURED, GO TO 243)
220. Before this survey, has your blood pressure ever been checked?
NO 2
221. Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?
NO 2
222. To lower your blood pressure, are you now taking a prescribed medicine?
NO 2
223. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.
224. May I take your blood pressure at this time?
NO 2 (GO TO 236)
225. RECORD TIME OF SECOND BP READING
MINUTES__
226. TAKE THE SECOND BLOOD PRESSURE READING, RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 236)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 236)
OTHER 996 (IF NOT MEASURED, GO TO 236)
227. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.
228. May I take your blood pressure at this time?
NO 2 (GO TO 239)
229. RECORD THE TIME OF THIRD BP READING
MINUTES__
230. TAKE THE THIRD BLOOD PRESSURE READING, RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (IF NOT MEASURED, GO TO 239)
TECHNICAL PROBLEM 995 (IF NOT MEASURED, GO TO 239)
OTHER 996 (IF NOT MEASURED, GO TO 239)
231. RECORD THE SUM OF SYSTOLIC MEASURES FROM 225 AND 230
232. CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDNG THE SUM IN 231 BY 2
233. RECORD THE SUM OF DIASTOLIC MEASURES FROM 226 AND 230.
234. CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVDING THE SUM IN 233 BY 2.
235. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE. (236 AND 237)
236. RECORD THE SYSTOLIC MEASURE FROM 219.
237. RECORD THE DIASTOLIC MEASURE FROM 219.
238. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECON DSYSTOLIC AND DIASTOLIC NUMBERS HERE. (239 AND 240)
239. RECORD THE SYSTOLIC MEASURE FROM 226.
240. RECORD THE DIASTOLIC MEASURE FROM 226.
241. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.
AVERAGE DIASTOLIC LESS THAN 85 2
AVERAGE DIASTOLIC FROM 85 TO 89 3
AVERAGE DIASTOLIC FROM 90 TO 99 4
AVERAGE DIASTOLIC FROM 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 2
AVERAGE DIASTOLIC FROM 85 TO 89 3
AVERAGE DIASTOLIC FROM 90 TO 99 4
AVERAGE DIASTOLIC FROM 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 3
AVERAGE DIASTOLIC FROM 85 TO 89 3
AVERAGE DIASTOLIC FROM 90 TO 99 4
AVERAGE DIASTOLIC FROM 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 4
AVERAGE DIASTOLIC FROM 85 TO 89 4
AVERAGE DIASTOLIC FROM 90 TO 99 4
AVERAGE DIASTOLIC FROM 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 5
AVERAGE DIASTOLIC FROM 85 TO 89 5
AVERAGE DIASTOLIC FROM 90 TO 99 5
AVERAGE DIASTOLIC FROM 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 6
AVERAGE DIASTOLIC FROM 85 TO 89 6
AVERAGE DIASTOLIC FROM 90 TO 99 6
AVERAGE DIASTOLIC FROM 100 TO 109 6
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
242. RECORD THE NUMBER YOU CIRCLED IN 241 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.
18-49 YEARS (SKIP TO 245)
50 YEARS AND ABOVE 3 (GO TO 203 FOR WOMAN OR, IF NO MORE WOMEN, GO TO 303)
244. CHECK 204: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
245. ASK CONSENT FOR ANEMIA TEST.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
246. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN)_______ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)
247. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2 (SKIP TO 254)
DON'T KNOW 8 (SKIP TO 254)
248. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
249. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
250. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)____ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
251. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
252. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)___ (SKIP TO 256)
NOT PRESENT/OTHER 3 (SKIP TO 256)
253. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
254. PREPARE EQUPMENT AND SUPPLIES FOR ANEMIA TEST AND PROCEED WITH THE TEST.
255. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
256. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.
WEIGHT, HEIGH, AND BLOOD PRESSURE MEASUREMENT FOR MEN AGE 15 AND ABOVE
301. CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303 AND 304. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
302. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 10 AND NAME FROM COLUMN 2.
NAME___
303. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18 YEARS AND ABOVE 2
304. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8
OTHER 2
NOT PRESENT 99994 (GO TO 303 FOR NEXT MAN OR, IF NO MORE MEN, END INTERVIEW)
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
307. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
18 YEARS AND ABOVE 2 (SKIP TO 313)
309. CHECK 304: MARITAL STATUS
OTHER 2 (SKIP TO 313)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT
310. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED
311. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 410 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)'s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)'s blood pressure?
312. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)___ (GO TO 343)
ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
313. ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.
I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart.
The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test or you can say no. It is up to you to decide.
Will you allow me to measure your blood pressure?
314. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN)___ (SKIP TO 343)
315. Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:
a) Eaten anything?
b) Had coffee, tea, cola or other drink that has caffeine?
c) Smoked or used any tobacco products?
d) Took alcohol?
NO 2
NO 2
NO 2
NO 2
316. May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment. MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETERS.
317. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.
UNIVERSAL: 22 CM TO 42 CM 2
LARGE; 36 CM TO 45 CM 3
318. RECORD TIME OF FIRST BP READING.
MINUTES ___
319. TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (GO TO 343)
TECHNICAL PROBLEM 994 (GO TO 343)
OTHER 996 (GO TO 343)
320. Before this survey, has your blood pressure ever been checked?
NO 2
321. Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?
NO 2
322. To lower your blood pressure, are you now taking a prescribed medicine?
NO 2
323. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.
324. May I take your blood pressure at this time?
NO 2 (GO TO 336)
325. RECORD TIME OF SECOND BP READING.
MINUTES__
326. TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (GO TO 336)
TECHNICAL PROBLEM 994 (GO TO 336)
OTHER 996 (GO TO 336)
327. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.
328. May I take your blood pressure at this time?
NO 2 (GO TO 339)
329. RECORD TIME OF THIRD BP READING
MINUTES___
330. TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
DIASTOLIC ___
REFUSED 994 (GO TO 339)
TECHNICAL PROBLEM 995 (GO TO 339)
OTHER 996 (GO TO 339)
331. RECORD THE SUM OF THE SYSTOLIC MEASURES FROM 326 AND 330.
332. CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDING THE SUM IN 331 BY 2.
333. RECORD THE SUM OF THE DIASTOLIC MEASURES FROM 326 AND 330.
334. CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVIDNG THE SUM IN 333 BY 2.
335. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.
336. RECORD THE SYSTOLIC MEASURE FROM 319.
337. RECORD THE DIASTOLIC MEASURE FROM 319.
338. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.
339. RECORD THE SYSTOLIC MEASURE FROM 326.
340. RECORD THE DIASTOLIC MEASURE FROM 326.
341. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.
AVERAGE DIASTOLIC LESS THAN 85 2
AVERAGE DIASTOLIC 85 TO 89 3
AVERAGE DIASTOLIC 90 TO 99 4
AVERAGE DIASTOLIC 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 2
AVERAGE DIASTOLIC 85 TO 89 3
AVERAGE DIASTOLIC 90 TO 99 4
AVERAGE DIASTOLIC 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 3
AVERAGE DIASTOLIC 85 TO 89 3
AVERAGE DIASTOLIC 90 TO 99 4
AVERAGE DIASTOLIC 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 4
AVERAGE DIASTOLIC 85 TO 89 4
AVERAGE DIASTOLIC 90 TO 99 4
AVERAGE DIASTOLIC 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 5
AVERAGE DIASTOLIC 85 TO 89 5
AVERAGE DIASTOLIC 90 TO 99 5
AVERAGE DIASTOLIC 100 TO 109 5
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
AVERAGE DIASTOLIC LESS THAN 85 6
AVERAGE DIASTOLIC 85 TO 89 6
AVERAGE DIASTOLIC 90 TO 99 6
AVERAGE DIASTOLIC 100 TO 109 6
AVERAGE DIASTOLIC GREATER OR EQUAL TO 110 6
343. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.
FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
___
SUPERVISOR'S OBSERVATIONS
____