| PARTICIPANT DEMOGRAPHIC DETAILS: |
| 1 |
Age in completed years: If available, Date of birth:______ |
8 |
Family type: [1- single/2- joint or size up to 5 or any other distinctive features/3- joint] ____ |
| 2 |
Participant ID/ Village name/ Household no: ___________/_____________/_____________ |
9 |
Caste: [1- SC/2- low caste/3- artisan caste/ 4- agriculture caste/5- prestige caste/6- dominant caste] ___ |
| 3 |
Marital status: [0-unmarried/1-married] ______ |
10 |
Land: [0- no land/1- <1 acre/2- 1-5 acre/3- 5-10 acre/4- 10-15 acre/5- 15-20 acre/6- 20 & > acre]______ |
| 4 |
Education of the participant: (completed schooling) [0- illiterate/1- 1st to 5th /2- 6th to 8th /3- 9th to 10th /4 – 11th to 12th / 5- graduate] _____ |
11 |
Social participation: [0- none/1- member of 1 organization /2- member of > 1 organization / 3- office holder in such an organization/4- wide public leader] _____ |
| 5 |
Occupation of the participant: [0- student/1- housemaker/2- labor/3- others (specify)] ___________ |
12 |
House: [0- no house/1- hut/2- kutcha/3- mixed/ 4- pukka/5- mansion] _______ |
| 6 |
Education of the mother/ guardian of the participant: [0-illiterate/1-1st to 5th /2-6th to 8th /3- 9th to 10th / 4 – 11th to 12th / 5-graduate] __________ |
13 |
Farm power:[1- no draught animals/2- 1-2 draught animals/4- 3-4 draught animals/6- 5-6 draught animals] _______ |
| 7 |
Religion: [0-Hindu/1-Christian/2-Muslim/3-sikh /4-others(specify)] _______ |
14 |
Material possessions: [0-bullock cart/1-cycle/2-radio/3-chairs/4-mobile phone/5-television/ 6-refrigerators] ______ |
| DETAILS OF MENSTRUAL HISTORY: |
| 15 |
Have you attained menarche? [1-yes.0-no] If yes, go to the next question. |
|
| 16 |
Age at menarche in completed years |
|
| 17 |
What is your average duration of menstruation in days per menstrual cycle? |
|
| 18 |
In the last period, how many days was the menstrual flow? |
|
| 19 |
What is the interval in days between two cycles? |
|
| 20 |
What are the health-related problems you faced during menstruation? |
Dysmenorrhea /Menorrhagia / Hypo menorrhea/Oligomenorrhea/ Polymenorrhea/ Premenstrual symptoms/ Backache /Others (specify)______________ |
| MEDICATION HISTORY RELATED TO WIFS: |
| 21 |
History of deworming in the last 6 months [1-yes.0-no] |
|
| 22 a |
Have you taken iron-folic acid (IFA) through WIFS in school? [1-yes.0-no] |
|
| 22 b |
If yes, the number of tablets consumed in the last 3 months |
|
| 23 |
Hemoglobin value in gm/dL |
|
