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Questions marked with an * are required Exit Survey
 
 
* Current Date
 
 
* Patient Code
   
 
 
* Interviewer Code
   
 
 
House Number
   
 
 
Cell Phone Number
   
 
 
 
Section A - Demographics/General Health
 
 
What is your civil status?
 
Married
 
Single
 
Cohabitating
 
Separated
 
Widowed
 
Divorced
 
NS/NR
 
Other
 
 
 
 
Which village do you currently live in?
 
Santa Tomas
 
Santa Clara