BIOMARKER QUESTIONNAIRE
PLACE NAME _______________
NAME OF HOUSEHOLD HEAD ____________
CLUSTER NUMBER ________
HOUSEHOLD NUMBER ________
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
FIRST VISIT
DATE ____
FIELDWORKER'S NAME ____
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE____
FIELDWORKER'S NAME____
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
FIELDWORKER'S NAME____
FINAL VISIT
DAY____
MONTH____
YEAR 201_
TOTAL NUMBER OF VISITS____
NOTES: __________________
TOTAL ELIGIBLE MEN ____
TOTAL ELIGIBLE CHILDREN ____
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW ____
AFRIKAANS 02
isiXHOSA 03
isiZULU 04
seSOTHO 05
seTSWANA 06
sePEDI 07
siSWATI 08
tshiVENDA 09
xiTSONGA 10
isiNDEBELE 11
HOME LANGUAGE OF RESPONDENT ____
AFRIKAANS 02
isiXHOSA 03
isiZULU 04
seSOTHO 05
seTSWANA 06
sePEDI 07
siSWATI 08
tshiVENDA 09
xiTSONGA 10
isiNDEBELE 11
TRANSLATOR USED
NO 2
SUPERVISOR
NAME ____
NUMBER ____
WEIGHT, HEIGHT AND HAEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
101) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER AND NAME OF ELIGIBLE CHILDREN AGE 0-5 IN THE SAME ORDER THEY APPEAR. IF THERE ARE MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
102) CHECK LIST OF CHILDREN ELIGIBLE FRO BIOMARKERS:
RECORD LINE NUMBER AND NAME
NAME ____
103) What is (NAME)'s date of birth?
MONTH ____
YEAR ________
104) CHECK 103: CHILD BORN BETWEEN 2011-2016?
NO 2 (GO TO 114)
104A) RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.
104B) ASK CONSENT FOR ANTHROPOMETRY FROM PARENT/OTHER ADULT.
104C) CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) ________________
NOT PRESENT/OTHER 3
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
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 PREVIOUS 5 MONTHS?
OLDER 2
111) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT
112) CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) __________
NOT PRESENT/OTHER
113) RECORD HAEMOGLOBIN LEVEL HERE AND IN THE CHILD HEALTH INFORMATIONAL BROCHURE.
NOT PRESENT 994
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, WAIST, BLOOD PRESSURE, HAEMOGLOBIN MEASUREMENT, BLOOD COLLECTION FOR HBA1C AND HIV TESTING, AND RECORDING OF MEDICINES FOR WOMEN AGE 15-95
201) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202. WRITE THE NAME OF EACH WOMAN AT THE TOP OF THE FOLLOWING PAGES. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202) CHECK LIST OF WOMEN ELIGIBLE FOR BIOMARKERS:
RECORD LINE NUMBER, NAME, AND AGE.
RECORD MARITAL STATUS
NAME __________
AGE ____
NEVER IN UNION 1
OTHER 2
18-95 YEARS (GO TO 202C)
202B) CHECK 202: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANTHROPOMETRY
202C) ASK CONSENT FOR ANTHROPOMETRY.
202D) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 205) __________
NOT PRESENT/OTHER 3 (GO TO 205)
202E) RECORD NAME OF PARENT/ADULT RESPONSIBLE FOR MINIOR.
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANTHROPOMETRY
202F) ASK CONSENT FOR ANTHROPOMETRY.
202G) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND GO TO 205) __________
NOT PRESENT/OTHER 3 (GO TO 205)
MINOR RESPONDENT CONSENT FOR ANTHROPOMETRY
202H) ASK CONSENT FOR ANTHROPOMETRY.
202I) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________
NOT PRESENT/OTHER 3
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
206A) WAIST CIRCUMFERENCE IN CENTIMETERS
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
18-95 YEARS 2 (GO TO 210)
209) CHECK 202: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
210) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT
211) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 247)
NOT PRESENT/OTHER 3 (GO TO 247)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT
213) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT.
214) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 255)
NOT PRESENT/OTHER 3 (GO TO 255)
MINOR RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
215) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT.
216) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 255)
NOT PRESENT/OTHER 3 (GO TO 255)
217) 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 any tobacco product?
d) Used any other type of tobacco such as chewing tobacco or snuff?
NO 2
NO 2
NO 2
NO 2
218) 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.
219) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.
MEDIUM: 23 CM - 31 CM 2
LARGE: 32 CM - 42 CM 3
EXTRA LARGE: GREATER THAN 43 CM 4
220) RECORD TIME OF FIRST BLOOD PRESSURE READING
MINUTES ____
221) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
FIRST BLOOD PRESSURE MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994 (IF NOT MEASURED, GO TO 245)
TECHNICAL PROBLEMS 995 (IF NOT MEASURED, GO TO 245)
OTHER 996 (IF NOT MEASURED, GO TO 245)
222) Before this survey, has your blood pressure ever been checked?
NO 2
223) 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
224) To lower you blood pressure, are you now taking a prescribed medicine?
NO 2
225) CHECK THAT IT HAS BEEN AT LEAST 3 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT
226) May I take your blood pressure at this time?
NO 2 (GO TO 243)
227) RECORD TIME OF SECOND BLOOD PRESSURE READING.
MINUTES ____
228) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
SECOND BLOOD PRESSURE MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994 (IF NOT MEASURED, GO TO 243)
TECHNICAL PROBLEMS 995 (IF NOT MEASURED, GO TO 243)
OTHER 996 (IF NOT MEASURED, GO TO 243)
229) CHECK THAT IT HAS BEEN AT LEAST 3 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT
230) May I take your blood pressure at this time?
NO 2 (GO TO 243)
231) RECORD TIME OF THIRD BLOOD PRESSURE READING.
MINUTES ____
232) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
THIRD BLOOD PRESSURE MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996
243) CIRCLE THE SINGLE NUMBER WHERE THE FINAL READING OF THE DIASTOLIC AND SYSTOLIC MEASURES MEET.
2 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
2 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
3 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
4 FINAL SYSTOLIC: LESS THAN 130
4 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
5 FINAL SYSTOLIC: LESS THAN 130
5 FINAL SYSTOLIC: 130-139
5 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
6 FINAL SYSTOLIC: LESS THAN 130
6 FINAL SYSTOLIC: 130-139
6 FINAL SYSTOLIC: 140-159
6 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
244) RECORD THE NUMBER YOU CIRCLED IN 243 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.
18-95 YEARS 2 (GO TO 247)
246) CHECK 202: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANAEMIA TEST
247) ASK CONSENT FOR ANAEMIA TEST.
248) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 249)
NOT PRESENT/OTHER 3 (GO TO 249)
50-95 YEARS (GO TO 249)
NO 2
DON'T KNOW 8
ADULT RESPONDENT CONSENT FOR HBA1C TESTING
249) ASK CONSENT FOR HBA1C TESTING.
250) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
RESPONDENT REFUSED 2 (SIGN) __________
NOT PRESENT/OTHER 3 (GO TO 271)
ADULT RESPONDENT CONSENT FOR HIV TESTING
251) ASK CONSENT FOR HIV TESTING.
252) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) __________ (GO TO 271)
________
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
253) ASK CONSENT FOR ADDITIONAL TESTING.
254) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 271) __________
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANAEMIA TEST
255) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/ADULT.
256) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 259)
NOT PRESENT/OTHER 3 (GO TO 259)
MINOR RESPONDENT CONSENT FOR ANAEMIA TEST
258) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 259)
NOT PRESENT/OTHER 3 (GO TO 259)
NO 2
DON'T KNOW 8
PARENTAL/RESPONSIBLE ADULT CONSENT FOR HBA1C TESTING
259) ASK CONSENT FOR HBA1C TESTING FROM PARENT/ADULT.
260) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 263)
NOT PRESENT/OTHER 3 (GO TO 271)
MINOR RESPONDENT CONSENT FOR HBA1C TESTING
261) ASK CONSENT FOR HBA1C TESTING FROM MINOR RESPONDENT.
262) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
MINOR RESPONDENT REFUSED 2 (SIGN) __________
NOT PRESENT/OTHER 3 (GO TO 271)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR HIV TESTING
263) ASK CONSENT FOR HIV TESTING FROM PARENT/ADULT.
264) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) __________ (GO TO 271)
______
MINOR RESPONDENT CONSENT FOR HIV TESTING
265) ASK CONSENT FOR HIV TESTING FROM MINOR RESPONDENT.
266) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 271)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
267) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
268) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 271)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
269) ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
270) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________
271) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
IF ADULT RESPONDENT, CHECK 254; IF MINOR RESPONDENT, CHECK 268 AND 270.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
273) RECORD HAEMOGLOBIN LEVEL HERE AND IN THE ADULT HEALTH INFORMATIONAL BROCHURE.
NOT PRESENT 994
REFUSED 995
OTHER 996
274) HBA1C TESTING: PLACE BAR CODE LABEL.
(PUT THE 1ST BAR CODE LABEL HERE.)
REFUSED 99995
OTHER 99996
275) HIV TESTING: PLACE BAR CODE LABEL.
(PUT THE 2ND BAR CODE LABEL HERE.)
REFUSED 99995
OTHER 99996
275A) OFFER HIV SELF-TEST KIT TO RESPONDENT WHO CONSENTED TO HIV TESTING.
TEST KIT REFUSED 2
TEST KIT NOT OFFERED 3
NOT PRESENT 4
OTHER 6
276) CHECK 274 AND 275: AT LEAST ONE BAR CODE LABEL PRESENT?
IF CONSENT GRANTED FOR EITHER TEST, PUT 3RD BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER CARD AND THE 4TH BAR CODE ON THE TRANSMITTAL FORM.
277) Please show me all the prescribed medicines that you take regularly or daily.
RECORD ALL MEDICATION/DRUG NAMES.
NONE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
278) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE.
WEIGHT, HEIGHT, WAIST, BLOOD PRESSURE, HAEMOGLOBIN MEASUREMENT, BLOOD COLLECTION FOR HBA1C AND HIV TESTING, AND RECORDING OF MEDICINES FOR MEN AGE 15-95
301) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302. WRITE THE NAME OF EACH MAN AT THE TOP OF THE FOLLOWING PAGES. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRES(S).
302) CHECK LIST OF MEN ELIGIBLE FOR BIOMARKERS:
RECORD LINE NUMBER, NAME, AND AGE.
RECORD MARITAL STATUS.
NAME ___________
AGE ____
OTHER 2
18-95 YEARS 2 (GO TO 302C)
302B) CHECK 302: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANTHROPOMETRY
302C) ASK CONSENT FOR ANTHROPOMETRY.
302D) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 305)
NOT PRESENT/OTHER 3 (GO TO 305)
302E) RECORD NAME OF PARENT/ADULT RESPONSIBLE FOR MINOR.
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANTHROPOMETRY
302F) ASK CONSENT FOR ANTHROPOMETRY.
302G) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND GO TO 305) ________
NOT PRESENT/OTHER 3 (GO TO 305)
MINOR RESPONDENT CONSENT FOR ANTHROPOMETRY
302H) ASK CONSENT FOR ANTHROPOMETRY.
302I) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) ________
NOT PRESENT/OTHER 3
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
306A) WAIST CIRCUMFERENCE IN CENTIMETERS.
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
307) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
18-95 YEARS 2 (GO TO 310)
309) CHECK 302: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
310) ASK CONSENT FOR BLOOD PRESSURE
311) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 347)
NOT PRESENT 3 (GO TO 347)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR BLOOD PRESSURE MEASUREMENT
313) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT.
314) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHE RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 355)
NOT PRESENT/OTHER 3 (GO TO 355)
MINOR RESPONDENT CONSENT FOR BLOOD PRESSURE MEASUREMENT
315) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT.
316) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 355)
NOT PRESENT/OTHER 3 (GO TO 355)
317) 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 any tobacco product?
d) Used any other type of tobacco such as chewing tobacco or snuff?
NO
NO
NO
NO
318) 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.
319) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.
MEDIUM: 23 CM-31 CM 2
LARGE: 32 CM-42 CM 3
EXTRA LARGE: GREATER THAN OR EQUAL TO 43 CM 4
320) RECORD TIME OF FIRST BP READING
MINUTES ____
321) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
FIRST BP MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994 (IF NOT MEASURED, GO TO 345)
TECHNICAL PROBLEMS 995 (IF NOT MEASURED, GO TO 345)
OTHER 996 (IF NOT MEASURED, GO TO 345)
322) Before this survey, has your blood pressure ever been checked?
NO 2
323) 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
324) To lower your blood pressure, are you now taking a prescribed medicine?
NO 2
325) CHECK THAT IT HAS BEEN AT LEAST 3 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.
326) May I take your blood pressure at this time?
NO 2 (GO TO 343)
327) RECORD TIME OF SECOND BP READING
MINUTES ____
328) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
SECOND BP MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994 (IF NOT MEASURED, GO TO 343)
TECHNICAL PROBLEMS 995 (IF NOT MEASURED, GO TO 343)
OTHER 996 (IF NOT MEASURED, GO TO 343)
329) CHECK THAT IT HAS BEEN AT LEAST 3 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.
330) May I take your blood pressure at this time?
NO 2 (GO TO 343)
331) RECORD TIME OF THIRD BP READING
MINUTES ____
332) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE AND PULSE (HEART RATE).
THIRD BP MEASURE
DIASTOLIC ____
PULSE ____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996
343) CIRCLE THE SINGLE NUMBER WHERE THE FINAL READING OF THE DIASTOLIC AND SYSTOLIC MEASURES MEET.
2 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
2 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
3 FINAL SYSTOLIC: LESS THAN 130
3 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
4 FINAL SYSTOLIC: LESS THAN 130
4 FINAL SYSTOLIC: 130-139
4 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
5 FINAL SYSTOLIC: LESS THAN 130
5 FINAL SYSTOLIC: 130-139
5 FINAL SYSTOLIC: 140-159
5 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
6 FINAL SYSTOLIC: LESS THAN 130
6 FINAL SYSTOLIC: 130-139
6 FINAL SYSTOLIC: 140-159
6 FINAL SYSTOLIC: 160-179
6 FINAL SYSTOLIC: GREATER THAN 180
344) LOCATE THE NUMBER YOU CIRCLED IN 343 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.
18-95 YEARS 2 (GO TO 347)
346) CHECK 302: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANAEMIA TEST
347) ASK CONSENT FOR ANAEMIA TEST.
348) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 349)
NOT PRESENT/OTHER 3
ADULT RESPONDENT CONSENT FOR HBA1C TESTING
349) ASK CONSENT FOR HBA1C TESTING.
350) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (SIGN) __________
NOT PRESENT 3 (GO TO 371)
ADULT RESPONDENT CONSENT FOR HIV TESTING
351) ASK CONSENT FOR HIV TESTING.
352) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) __________ (GO TO 371)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
353) ASK CONSENT FOR ADDITIONAL TESTING.
354) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 371)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANAEMIA TEST
355) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/ADULT.
356) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 359)
NOT PRESENT/OTHER 3 (GO TO 359)
MINOR RESPONDENT CONSENT FOR ANAEMIA TEST
357) ASK CONSENT FOR ANAEMIA TEST FROM RESPONDENT.
358) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 359)
NOT PRESENT/OTHER 3 (GO TO 359)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR HBA1C TESTING
359) ASK CONSENT FOR HBA1C TESTING FROM PARENT/ADULT.
360) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________
(GO TO 363)
NOT PRESENT/OTHER 3 (GO TO 371)
MINOR RESPONDENT CONSENT FOR HBA1C TESTING
361) ASK CONSENT FOR HBA1C TESTING FROM MINOR RESPONDENT.
362) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
MINOR RESPONDENT REFUSED 2 (SIGN) __________
NOT PRESENT/OTHER 3 (GO TO 371)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR HIV TESTING
363) ASK CONSENT FOR HIV TESTING FROM PARENT/ADULT.
364) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) __________ (GO TO 371)
MINOR RESPONDENT CONSENT FOR HIV TESTING
365) ASK CONSENT FOR HIV TESTING FROM MINOR RESPONDENT.
366) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________ (GO TO 371)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
367) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
368) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 371)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
369) ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
370) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) __________
371) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
IF ADULT RESPONDENT, CHECK 354; IF MINOR RESPONDENT, CHECK 368 AND 370.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
373) RECORD HAEMOGLOBIN LEVEL HERE AND IN ADULT HEALTH INFORMATIONAL BROCHURE.
NOT PRESENT 994
REFUSED 995
OTHER 996
374) HBA1C TESTING: PLACE BAR CODE LABEL.
(PUT THE 1ST BAR CODE LABEL HERE.)
REFUSED 99995
OTHER 99996
375) HIV TESTING: PLACE BAR CODE LABEL.
(PUT THE 2ND BAR CODE LABEL HERE.)
REFUSED 99995
OTHER 99996
375A) OFFER HIV SELF-TEST KIT TO RESPONENT WHO CONSENTED TO HIV TESTING.
TEST KIT REFUSED 2
TEST KIT NOT OFFERED 3
NOT PRESENT 4
OTHER 6
376) CHECK 374 AND 375: AT LEAST ONE BAR CODE LABEL PRESENT?
IF CONSENT GRANTED FOR EITHER TEST, PUT 3RD BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER CARD AND THE 4TH BAR CODE ON THE TRANSMITTAL FORM.
377) Please show me all the prescribed medicines that you take regularly or daily.
RECORD ALL MEDICATION/DRUG NAMES.
NONE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
378) 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.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS: _______________
SUPERVISOR'S OBSERVATIONS: ___________