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Exit Survey
 
 
EXIT SURVEY FOR ALL CLIENTS AVAILING OF FP COUNSELING/METHODS/SERVICES IN FACILITY
 
 
D. INFORMATION ABOUT THE PATIENT
 
 
D.1 Age as of her last birthday (Edad)
   
 
 
D.2 Date of Birth (Petsa ng Kapanganakan)
 
 
D.3 Marital Status (Estado Sibil)
 
Single/never married
 
Currently married
 
Living together
 
Separated/Annulled
 
Widowed
 
 
D.4 Religion (Relihiyon)
 
Roman Catholic
 
Protestant
 
Iglesia ni Kristo
 
Aglipay
 
Islam
 
None
 
Other
 
 
 
OBSTETRIC HISTORY Note to Enumerators: Twin/multiple births are counted as ONE (1) pregnancy
 
 
D.5.1 How many full term pregnancies (37-42 weeks/ 9 months) did you have? Ilang pagbubuntis ang sapat sa buwan o “full-term”? (9 na buwan, o 37-42 na lingo)?
   
D.5.2 How many pre-term pregnancies (more than 20 weeks to less than 37 weeks/more than 5 months to less than 9 months) did you have? Ilang pagbubuntis ang kulang sa buwan o “pre-term” (mula ika-20 lingo hanggang sa ika-36 na lingo; o mula 5 buwan hanggang kulang sa 9 buwan?)
   
D.5.3 How many cases of abortions (terminated pregnancies before 20 weeks/5 months) did you have? Ilang beses nakunan, o nalaglag ang ipinagbubuntis? (bago mag 20 lingo o 5 buwan)?
   
D.5.4 How many living children do you have? Ilan ang anak mong nabubuhay sa ngayon?