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  2. 2015
  3. September
  4. L
  5. Lifestyle choices and lead toxicity
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Name
   
 
 
 
Age
   
 
 
 
Sex 
 
Male
 
Female
 
Other
 
 
 
What is highest educational qualification held?
 
Illiterate
 
Primary
 
Secondary
 
Higher Secondary
 
Graduation
 
Post Graduation
 
Any other, specify
 
Other
 
 
 
 
Do you consume alcohol?
 
Yes
 
No
 
 
 
How often do you consume alcohol?
 
Daily
 
Weekly
 
Monthly
 
Quarterly
 
Ocassionally
 
 
 
Quantity of alcohol consumed each time
 
Less than 30ml
 
30ml
 
60ml
 
Quarter
 
half a bottle
 
One bottle
 
More than one bottle
 
 
 
Do you smoke?
 
Yes
 
No
 
 
 
What do you smoke?
 
Beedi
 
Cigarettes
 
Hookah
 
Other
 
 
 
 
how often do you smoke?
 
Daily
 
Weekly
 
Monthly
 
Quarterly
 
Occasionally
 
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