NAME AND SURNAME

ITEM NO.

RELATIONSHIP WITH GENDER

GENDER

AGE
Date of Birth

ANTHROPOMETRY

EDUCATION

PHYSICAL HANDICAP

Code

Day

Month

Year

Years

WEIGHT (kg)

HEIGHT (cm)

Years

Description

Code

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Relationship:

Gender:

Physical handicap

Spouse:

2

Male:

1

Legless:

1

Dumb:

6

Child:

3

Female:

2

One-armed:

2

III (in bed):

7

Parent:

4

Pregnant:

3

Paralytic:

3

Goitre (evident):

8

Other:

5

Lactating:

4

Blind:

4

Others:

9

Deaf:

5

None:

0