Health promotion for healthy diet and physical activity and its impact on cardiovascular health: A community-based trial among young mothers in a semiurban community of Nepal Questionnaire (baseline survey) I.
Basic information SN
Question
1
Serial Number of the respondent
2
Village
3
Ward no.
4
Street/Tole
5
House no
6
Phone number
7
Name of the head of household
8
Husband’s name
9
How many persons (adults and children) live permanently (6 months or more)
Answer
Code
1. Duwakot 2. Jhaukhel
|__|__| persons
in your household? 10
How many children aged less than 15 years (including responding child live
|__|__| children
permanently in your household?
II.
Demographic information
A. Respondent’s (mother’s) information Now I am going to ask you some information about yourself. 1
SN Question 11 Name of the respondent
Answer
12
What is your year of birth?
13
Relation to the head of household
14
What is your religion?
1. 2. 3. 4. 5.
Hindu Buddhism Christian Islam Others (Specify) ____________
15
What is your ethnicity?
1. 2. 3. 4. 5. 6. 7. 8. 9.
Newar Hill Brahmin Chhetri Tamang Dalit Thakuri Magar Rai Others( Specify)_____________
16
What is the highest level of education you have completed?
17
What is your main occupation?
Code
1. Head 2. Wife 3. Mother-in-law 4. Mother 5. Daughter-in-law 6. Other (specify) _____________________
1. 2. 3. 4. 5. 6. 7. 8. 9. 1. 2. 3. 4. 5. 6.
Cannot read and write No formal schooling but can read and write Less than primary school (
