Costing Form

Demographics

AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Encounter Details

Name of Dispensary:*

Provider ID *

Enter provider's system-id:*

Encounter Date:*

SECTION A - DEMOGRAPHICS

Enter Participant ID:*

Select Division *

Mosoriot units:*

Turbo units:*

village:*

What is the size of your house hold?*

Select Enrollment Strategy:*

During the past 12 months have you been told by a doctor or other health worker that you have raised blood pressure or hypertension? *

SECTION B - INPATIENT ADMISSIONS

Have you at any time during the past 12 months been admitted in a hospital for at least one night? *

SECTION C - NON-INPATIENT SERVICES

Have you at any time during the past 3 months received medical care at a Health Centre or Dispensary or a hospital where you did not spend at least one night? *

SECTION D - HERBAL MEDICINE/SPIRITUAL HEALER

Have you at any time during the past 3 months visited a herbalist or spiritual healer? *

SECTION E - PRESCRIBED MEDICINES

Have you TAKEN any medicines that were prescribed by your health care provider over the past 3 months? *

How many different types of prescriptions/medicines have you taken in the past 3 months?*

Don't Know Refused

We are now going to ask you some questions to find out more information about each of the PRESCRIPTION medicines you have TAKEN over the past 3 months.

1st prescription

What is the name of the medicine? *

Specify others

What medical condition or disease(s) was the prescription meant to address? *

Specify others

Where did you purchase the prescription from? *

How much did you pay for the medicine?*

Don't Know Refused

SECTION F - HEALTH INSURANCE

Do you have NHIF insurance? *

Have you ever used your NHIF insurance to pay for health services?*

Are you currently covered by any other health insurance apart from NHIF?*

Note which other insurance. *

SECTION G - LIFESTYLE/HABITS

We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work and as part of your house, to get from place to place, and in your spare time for recreation, exercise or sport. I am going to first ask you about vigorous activities then later ask about moderate activities that you did in the last seven days Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, running, playing foot ball or fast bicycling? *

How much time did you usually spend doing vigorous physical activities on days that you do them? *

Hours Minutes

Don't Know Refused

Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace? Do not include walking unless you are purposely walking at a fast pace. *

How much time do you usually spend doing moderate physical activities on days that you do them? *

Hours Minutes

Don't Know Refused

For the last one month, how many grams of salt did you purchase?*

Don't Know Refused

In a typical week, on how many days do you eat fruit? *

How many servings of fruit do you eat on one of those days? *

In a typical week, on how many days do you eat vegetables? *

How many servings of vegetables do you eat on one of those days? *

Tobacco Use

Are you currently using any form of tobacco? *

What form of tobacco do you currently use (i.e. cigarettes, pipe, sniffed, chew) *

How many cigarettes do you smoke each day? *

How many years have you used tobacco regularly?*

Alcohol Use

Are you currently drinking any form of alcohol?*

what form of alcohol do you use? *

Beer

Local Brew

Spirits & Wines

In a typical week, how many servings of alcohol do you consume? *

SECTION H - HEALTH STATUS

We are now going to ask you questions about your health-related quality of life.

How would you describe your mobility?*

How would you describe your Self-Care?*

How would you describe your usual Activities? (e.g. work, study, housework, family or leisure activities)*

How would you describe your pain/discomfort ?*

How would you describe your pain/depression ?*

We would like to know how good your health is TODAY.
The scale is numbered from 0 to 100.
100 means the BEST health you can imagine.
0 means the WORST health you can imagine

Please select the number you based on the scale*

SECTION I - WORK PRODUCTIVITY

What is your primary job*

Other job Specify *

How much do you earn per month before taxes and other deductions? include business income, wages and salary?*

What is the primary reason you are not working right now?*

Other reason Specify *

During the past 30 days, how many days did you miss from work because of your health problems? Include days/half days you missed on sick days, times you went in late, left early, etc., because of your health problems.*

What are the health problems that caused you to miss work? *

Specify others

during the past 7 days, how many hours did you miss from work due to your health problems?*

During the past 7 days, how many hours did you work? *

Hours
Minutes

Don't Know Refused

SECTION J - PHYSICAL MEASUREMENTS

Height (CM)

Weight (KG)

Waist circumference (CM)

Hip circumference (CM)

Blood Pressure

Systolic *

Diastolic *