Serial Number
Treatment Centre
Age (as at last birthday)
Raw Age
Gender
Religion
Marital status
If married, type of marriage
What is your tribe
Previous Occupation
Employment Status
Level of Education (Completed)
Do you smoke
If smoker specify amount of daily consumption (number of cigarettes/day)
Duration of smoking: yers; months
Previous exposure to a person who had cough for more than two weeks or a TB patient
Are you being treated for any other medical problem (eg. HIV/AIDS, Diabetes, COPD, Disability, etc)?
If yes please state the problem(s)
When do you see a doctor
When was the last time you had a complete physical examination
It is important to get tested to prevent disease
Have you had any health screening done before
If yes, please specify
Have you heard of Pulmonary tuberculosis
Source of information on TB (Multiple response)
What kind of disease do you have
Is Tuberculosis preventable
Is Tuberculosis treatable
Is Tuberculosis contagious
Is Tuberculosis hereditary
Do you know if there is a vaccine for TB
Do you know the approximated duration of treatment
Does having HIV/AIDS make one to be at risk of tuberculosis
Toal knowledge of T.B
Cough
Date of onset
Fever
Loss of Weight
Haemoptysis
Chest pain
Night sweat
Difficulty with breathing
Others (specify)
Which symptom(s) made you seek healthcare
Do you think there was a delay between the onset of your cough and the commencement of TB treatment
Fear of what would be found on diagnosis
Hoped your symptoms would go away on their own (denial and concealment)
Fear of social isolation
Economics constraints
Poor staff attitude
Poor quality of health services
Too far
Too busy/long waiting time
Bad experience
Your religion does not permit you from seeking health outside the home
Other (specify)
Time to reach from home to the nearest public health facility
Distance (in km) from home to the nearest health facility providing treatment
Distance to the nearest Facility
Residential Area
What was your first action, when you decided to seek care for your cough
Date first seen by a Formal-Health Care Provider (FHCP) for this current illness
What was the health facility of the FHCP whom you first sought his consultation
First Healthcare facility visited
If private practice in Q3 above, what is the specialty of the HCP whom you sought his consultation
What was the health facility of the second FHCP whom you sought his consultation
If private practice in Q5 above, what is the specialty of the HCP whom you sought his consultation
What was the health facility of the third FHCP whom you sought his consultation
If private in Q7 above, what is the specialty of the HCP whom you sought his consultation
Reasons of first consultation of the health facility (Mentioned in Q3) with the onset of symptoms
What were your reasons of non-consultation of health facility (coded 0,1,2 in Q3) with the onset of symptoms (in case he/she did not consult 0,1,2)
Availability of services in PHC/TB centres
Prompt action from HCP in PHC
PHC well equipped
PHC giving free medicine
There is enough PHC in the area
Health facility workload
Waiting time (0: <=15mn, 1:15-30mn; 2:>30mn-1 hr 3:>1hr)
Do you feel ashamed for having TB
Do you have to hide TB diagnosis from the other people
Does TB affect relations with the others
Is TB very costly due to long duration of the disease
Do you prefer to live isolated since you got TB diagnosis
Does the TB affect your work performance
Does TB affect your marital relation
Does TB affect family responsibility
Do you think there is less chances of marriage due t TB diagnosis
Does TB affect your family relations
Does TB cause female infertility
Does TB lead to serious complications during pregnancy
Does TB affect breast feeding
Does TB affect pregnancy outcome
Is a girl unable to decide for getting TB treatment
Stigmatization
Stigmatization Category
Date of first TB diagnosis
Number of health seeking encounters (HCP) before initial TB diagnosis
Health facility of the HCP who made the initial TB diagnosis
Specialty of the HCP who made the initial TB diagnosis
Sputum examination Date
X-ray
Both Sputum examination and X-ray
Date of test
Sputum only
HIV screening
Date of Initiation of treatment
Phase of treatmet
Patient delay in days
Doctor Delay
Diagnostic Delay
Treatment Delay
Health System Delay
Total Delay
Marital Status
Type of marraige
Type of marriage category
Family size
Number of dependents
Income per month (average)
Income Category
Duvall Developmental Family Stage
My family gives me the moral support i need
I get good ideas about how to do things or make things from my family
Most other people are closer to their family than i am
When i confide in the members of my family who are closest to me, i get the idea that it makes them uncomfortable
My family enjoys hearing about what i think
Members of my family share many of my interests
Certain members of my family come to me when they have problems or need advice
I rely on my family for emotional support
There is a member of my family i could go to if i were just feeling down, without feeling funny about it later
My family and I are very open about what we think about things
My family is sensitive to my personal needs
Members of my family come to me for emotional support
Members of my family are good at helping me solve problems
I have a deep sharing relationship with a number of members of my family
Members of my family get good ideas about how to do things or make things from me
When i confide in members of my family, it makes me uncomfortable
Members of my family seek me out for companionship
I think that my family feels that i'm good at helping them solve problems
I dont have a relationship with a member of my family that is as close as other people's relationships with family members
I wish my family were much different
Family support
I am satisfied that i can turn to my family for help when something is troubling me
I am satisfied with the way my family takes things over with me and shares my problems
I am satisfied that my family accepts and supports my wishes to take on new activities
I am satisfied with the way my family expresses affection and responds to my emotions
I am satisfied with the way my family and i chare time together
Family Apgar Score
Pulse
Blood pressure Systolic
Blood pressure Diastolic
Weight in Kg
Height in (m)
BMI
Knowledge of T.B Category
Satisfaction with care category
Patient delay category
Treatment Delay Category
Corrected Diagnostic delay
Diagnostic category
Family size Category
First action taking category
Number of health seeking encounter category
Level of Education category
Specialty Category
Health facility where the initial TB diagnosis Category
First action taking when seeking care for cough
First Healthcare facility visisted public/private
first action taken
time from symptomps to first consultation (patient delay category)
time from dignosis to treatment
how diagnosis was made
first formal healthcare provider visited
Second Formal Healthcare Provider Visited
Third Formal Healthcare Provider Visited
first symptoms noticed