1. Have you or any members of the household been ill in the last 2 weeks?

(exclude hospital admission)

Yes

No

2. Sex of person who has been ill*

Male

Female

3. Age (in years) of person who has been ill

Under 1

1-5

6-15

16-54

55 and older

4. What were the person’s symptoms? (mark one or more)

Diarrhoea
Cough
Fever
Others (specify)

5. What was done? (mark one or more)

Consulted traditional healer
Consulted public health clinic/hospital
Consulted private health clinic/hospital
Consulted pharmacist
Consulted drug seller

Sought advice from friend/neighbour/family
Bought medicine without consultation
Used medicine left from another illness
Did nothing
(If no one was consulted, go to question 10)

6. What was the person’s diagnosis, if any?

7. Was medication prescribed?

Yes

No

8. Which medicines were obtained?

All

Some

None

9. If not all, why not? (mark one or more)

Price was too high
Did not have enough money
Not able to borrow enough money
Too many medicines were prescribed
Did not believe all the medicines were needed
Started to feel better
No time to get all the medicines

Traditional healer did not have all the medicines
Public pharmacy did not have all the medicines
Private pharmacy did not have all the medicines
Drug seller did not have all the medicines
Already had some of the medicines at home
Other

10. How much of the prescribed medicine was taken?

All

Some

None

11. What medicines were used? (include traditional medicines) list one per line

Amount spent
(write 0 if free)

Mark an X through the source as numbered (1-9)

Local

US$

1. Traditional healer 2. Public health centre/hospital 3. Private health centre/hospital 4. Public pharmacy 5. Private pharmacy 6. Local store/marketplace 7. Friends/neighbours/family 8. Medicines already owned 9. Other

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

8

9

12. Estimated family weekly income OR total household expenses last week
Local __________________________
US$