Verbal Autopsy Questionnaire

Sr. No ______Date: ______

A. Demographic Information of Deceased:

Kindly confirm the name and age of patient to verify the hospital records

Name: ______Age at the time of death ______

  1. Can you remember the date of expiry? Yes/ No, (if yes kindly note this)

______

  1. Can you please tell me the gender of deceased
  2. Male1
  3. Female 2
  4. What was his/her marital status
  5. Married 1
  6. Unmarried2
  7. What was his/her Qualification
  8. Illiterate1
  9. Primary 2
  10. Secondary 3
  11. Above secondary 4
  12. Can you please specify his/her Job/Occupation
  13. Laborer1
  14. Service2
  15. Business3
  16. Unemployed 4
  17. Student5

B. Please tell me if deceased suffered from anyof the following illnesses before dengue infection

  1. DiabetesYes1No.2Don’t Know8
  1. High Blood pressureYes1No.2Don’t Know8
  1. AsthmaYes1No.2Don’t Know8
  1. EpilepsyYes1No.2Don’t Know8
  1. MalnutritionYes1No.2Don’t Know8
  1. CancerYes1No.2Don’t Know8
  1. TuberculosisYes1No.2Don’t Know8
  1. Cardiac disease Yes1No.2Don’t Know8
  1. HIV/AIDS? Hepatitis B/CYes1No.2Don’t Know8
  1. Did she suffer from any other medically diagnosed illness?

Yes1No.2Don’t Know8

  1. Can you specify the illness?

______

  1. Any other physical co-morbidities.

______

C. Can you please describe the sign and symptoms of patients during hospital stay? I will ask questions one by one.

  1. Did he have a fever

Yes1No.2Don’t Know8

  1. Was the fever continuous or on and off?

Continuous1On and Off2 Don’t Know8

  1. Did he/she have chills/rigor?

Yes1No.2Don’t Know8

  1. Did he/she have a cough?

Yes1No.2Don’t Know8

  1. For how long did he/she have a cough?

Days1 Month 2 Don’t Know8

  1. Was the cough severe?

Yes1No.2Don’t Know8

  1. Was the cough productive with sputum?

Yes1No.2Don’t Know8

  1. Did he/she have cough out blood?

Yes1No.2Don’t Know8

  1. Did he/she have night sweets?

Yes1No.2Don’t Know8

  1. Didhe/she have breathlessness?

Yes1No.2Don’t Know8

  1. Did he/she have chest pain?

Yes1No.2Don’t Know8

  1. For how long did she have chest pain?

Days1Month 2 Don’t Know 8

  1. Did chest pain start suddenly or gradually?

Suddenly 1Gradually 2 Don’t Know8

  1. When he/she had severe chest pain, how long did it last?

Less than half and hour1Half an hour to 24 hours2

Longer than 24 hours3Don’t Know8

  1. Was the chest pain continuous or on and off?

Continuous 1On and Off 2Don’t Know8

  1. Did the chest pain get worse while coughing?

Yes1No.2Don’t Know8

  1. Did he/she have palpitations?

Yes1No.2Don’t Know8

  1. Did she have diarrhoea?

Yes1No.2Don’t Know8

  1. For how long did she have diarrhoea?

Yes1No.2Don’t Know8

  1. Was the diarrhoea continuous or on and off?

Yes1No.2Don’t Know8

  1. How many times did she pass stools in a day? Number9 Don’t Know 8
  1. Did he/she vomit?

Yes1No.2Don’t Know8

  1. For how long did he/she vomit?

Days1Months 2Don’t Know8

  1. Did the vomit look like a coffee-colored fluid or bright red/blood red or some other?
  2. Coffee-Coloured Fluid1
  3. Bright Red/Blood Red2
  4. Other 6
  5. Don’t Know8
  1. How many times did she vomit in a day?

Number 9 Don’t Know8

  1. Did she have abdominal pain?

Yes1No.2Don’t Know8

  1. For how long did he/she have abdominal pain?

Days1Months 2Don’t Know8

  1. Did he/she have abdominal distension?

Days1Months 2Don’t Know8

  1. Did the distension develop rapidly within days or gradually over months?
  2. Rapidly within days1
  3. Gradually over months2
  4. Don’t know8
  1. Was there a period of a day or longer during which she did not pass any stool?

Yes1No.2Don’t Know8

  1. Did he/she have difficulty or pain while swallowing food?

Yes1No.2Don’t Know8

  1. Did he/she have headache?

Yes1No.2Don’t Know8

  1. For how long did he/she the have headache?

Days1Months 2Don’t Know8

  1. Was the headache severe?

Yes1No.2Don’t Know8

  1. Did she have stiff or painful neck?

Yes1No.2Don’t Know8

  1. Did she have mental confusion?

Yes1No.2Don’t Know8

  1. For how long did he/she have mental confusion?

Days1Months 2Don’t Know8

  1. Did he/she become unconscious?

Yes1No.2Don’t Know8

  1. For how long was he/she unconscious?

Days1Months 2Don’t Know8

  1. Was there any change in color of urine?

Yes1No.2Don’t Know8

  1. For how long did she have the change in color of urine?

Days1Months 2Don’t Know8

  1. During the final illness did he/she ever pass blood in the urine?

Yes1No.2Don’t Know8

  1. For how long did he/she pass blood in the urine?

Days1Months 2Don’t Know8

  1. For how long did he/she have the skin rash?

Days1Don’t Know8

  1. Did he/she had rash on body?

Yes1No.2Don’t Know8

If yes then

  1. Was the rash on:
  1. The face?Face128
  2. The trunk?Trunk128
  3. The arms and legs?Arms and legs128
  4. Any other place?Other place128
  5. Specify ______
  1. Did he/ She has bleeding from mouth, nose, anis?

Yes1No.2Don’t Know8

  1. 64. Did he/she have any swelling?

Yes1No.2Don’t Know8

  1. For how long did he/she have the swelling?

Days1Months 2Don’t Know8

  1. Was the swelling on:
  2. The face?128
  3. The joints?128
  4. The Ankles?128
  5. The whole body?128
  6. Any other place?128
  7. Specify ______
  1. Did she receive any treatment for the illness that led to death?

Yes1No.2Don’t Know8

  1. Can you please list the drugs she was given for the illness that led to death?

______

  1. What type of treatment did she receive?

YesNoDK

  1. Ors/drip treatment128
  2. Blood Transfusion128
  3. N/G feeding(Through the nose)128
  4. Other______

D. Death Certificate:

  1. Do you have a death certificate for the deceased?

Yes1No.2Don’t Know8

  1. Can I see the death certificate?

Day______Month______Year______

  1. Copy day, month and year of issue of death certificate?

Day______Month ______Year______

  1. Record the cause of death from the first (top) line of the death certificate?

______

  1. Record the cause of death from the second line of the death certificate (if any)?

______

  1. Burial place:

______

Interviewer’s Observations

To be filled in after completing interview

______

Comments on specific questions:

______

Any other comments:

______

Supervisors observations

______Name of the supervisor:______Dated:______

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