Questionnaire on Sexually Transmitted Infections

Topics: Sexual intercourse, Vagina, Penis Pages: 5 (841 words) Published: March 15, 2011
Questionnaire on Sexually Transmitted Infections

For face-to-face interviewing women aged 15 to 49 in FilaBavi, Vietnam

Date of interview:...../...../.....time….. Date of supervision:......./......./........ Name of interviewer:.............Duration…….. Name of field supervisor:..................... Comments of interviewer on respondent’s Comments of field supervisor cooperation……………………………… …………………………………………. ………………………………………… ………………………………………….

I. General information:
Commune................ Cluster number................ Household code................ Name ...............................................Age................ ID number................ Ethnic group: (1. Kinh (2. Muong (3. Other

1. a, Your occupation:
(1. Farmer(2. Government staff(3. Worker
(4. Trader(5. Student(6. Housewife
(7. Unemployed(8. Hired labor
(9. Service (please specify)....................................................................... (10. Other (please specify)....................................................................................... b, Do you have to soak your body into water while working? (0. No (1. Yes 2. Your education:

(1. Illiterate(2. Primary(3. Secondary school
(4. High school(5. College or University
3. a, Your marital status at present:
(1. Unmarried (2. Married, living with husband/partner (3. Separated (4. Divorced
(5. Widowed
b, Year of your first marriage?………………
4. Have you had any children? (0. No (1. Yes, If yes, how many ………… 5. Which of the following events have you ever experienced?
| | |No |Yes |How many times |When was the last time? | |1 |Induced abortion | | | | | |2 |Miscarriage | | | | | |3 |Still birth | | | | | |4 |Premature birth | | | | | |5 |Neonatal death | | | | |

6. What contraceptive methods are you currently using? (can be many) (1. Intrauterine device(2. Condom
(3. Calendar/mucus method(4. Withdrawal
(5. Contraceptive pill(6. Male sterilization
(7. Female sterilization
(8. Others (please specify)....................................................................... (9. None

II. Questions about STI knowledge

7. a, What do you think about vaginal discharge in women?
(1. Normal(2. Abnormal(3. Don't know
(1. Seldom(2. Common (3. Don't know
b, How would you define vaginal discharge as abnormal? (can be many) (1. Greater amount than usual(0. No(1. Yes
(2. Odor(0. No(1. Yes
(3. Yellow or green discharge (0. No(1. Yes
(4. Powdery liquid(0. No(1. Yes
(5. Foamy liquid(0. No(1. Yes
(6. Blood-stained liquid(0. No(1. Yes
(7. Don't know
(8. Other (please specify)........................................................................................ 8. Do you know what are considered suspected symptoms of STI ? (can be many) (1. Abnormal vaginal discharge (female)

(2. Urethral discharge (male)
(3. Genital ulcers (4. Genital warts
(5. Genital itching (6. Pain during urination (7. Pain during sexual intercourse (8. Lower abdominal pain (female) (9. Don't know
(10. Other (please...
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