Diabetes and CVD Risk Management Enrollment Form

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Diabetes and CVD) risk management is a major part of the survey being undertaken at Patancheru, Medak District which includes, deafness, cervical cancer, prostate cancer, infant deafness and emergency medical systems. Note the detailed dietary questionnaire is can be limited to the individuals or villages targeted for blood draw for lipids if the overall length of then questionnaire is deemed too long or too time consuming

DATA ENTERED BY *

Please enter your name. No need of Prefixes or Suffixes

1. Baseline Information

1.1 NAME *

1.2 DATE OF BIRTH

1.3 AGE *

1.4 SEX *

FEMALE

MALE

1.5 MARITAL STATUS *

UNMARRIED

MARRIED

DIVORCED

WIDOWED

SEPARATED

1.6 Are you currently employed *

EMPLOYED FOR WAGES

SELF EMPLOYED

OUT OF WORK

HOME MAKER

STUDENT

RETIRED

UNABLE TO WORK

1.7 TYPE OF WORK *

AGRICULTURAL

MANUAL

OTHER

1.8 What is the highest grade or year of school you completed ? *

NEVER ATTENDED ANY SCHOOL

GRADES 1 THROUGH 10 (SSLC)

GRADES 11 THROUGH 12 (+2) OR PRE-UNIVERSITY

COLLEGE 3 TO 4 YEARS (COLLEGE GRADUATE )

TECHNICAL SCHOOL GRADUATE

POST GRADUATE

1.9 ALLERGIES *

1.10 DRUG ABUSE *

1.11 FATHER ALIVE *

If yes, skip to Q 1.14

Yes

1.12 If deceased - Age at death

1.13 If deceased - Cause of death

1.14 MOTHER ALIVE *

If yes, skip to next page by pressing "continue" to go to next page

Yes

1.15 If deceased - Age at death

1.16 If deceased - Cause of death

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