Maternity History
Form
CEN-MTHST-R18-V1
Village: 1 1
Dwelling:
1 1 1 1 A
Fieldworker: 1 1 1 1
Visit Date: Y Y Y Y M M D D
NOTE: This form is to complete the childbirth history of all mothers in the Agincourt study area. Children not listed on the household census form
must be included here.
Name:
1a
A A A A A A A A A A A A A A A
Surname:
1b
A A A A A A A A A A A A A A A
1
Mother’s Name and Surname
2
Mother’s Census ID
3
Name of First Child
4
Date of Birth:
5
Sex:
6
Outcome of the pregnancy?
7
Number of children born from this pregnancy?
8
Is the child living or dead?
9
Where is s/he living now?
10
How old was the child at the time of death?
2
A A A A A A A A A A A A A A A
3
A A A A A A A A A A A A A A A
4 Y Y Y Y M M D D
M = Male; F = Female
5
A
L = Live birth; S = Still birth; A = Abortion
6
A
7
1
8
A
9
A
10a
1 1
10b
A
L = LivingQ9
D = DeadQ10
V = Same Village; A = Agincourt Area;
B = Bushbuckridge Area; E = Elsewhere
(Enter days if < 1 month, enter months if between 1
month and 1 year, enter years if > 1 year)
(Age at death units)
11 Name of Second Child
1 1 1 1 1 1
D = Days; M = Months; Y = Years
A A A A A A A A A A A A A A A
11
A A A A A A A A A A A A A A A
12 Date of Birth:
12 Y Y Y Y M M D D
13 Sex:
14 Outcome of the pregnancy?
M = Male; F = Female
13
A
L = Live birth; S = Still birth; A = Abortion
14
A
15
1
16
A
17
A
18a
1 1
18b
A
15 Number of children born from this pregnancy?
16 Is the child living or dead?
17 Where is s/he living now?
18
How old was the child at the time of death?
L = LivingQ17
D = DeadQ18
V = Same Village; A = Agincourt Area;
B = Bushbuckridge Area; E = Elsewhere
(Enter days if < 1 month, enter months if between 1
month and 1 year, enter years if > 1 year)
(Age at death units)
19 Name of Third Child
D = Days; M = Months; Y = Years
A A A A A A A A A A A A A A A
19
A A A A A A A A A A A A A A A
20 Date of Birth:
20 Y Y Y Y M M D D
21 Sex:
22 Outcome of the pregnancy?
M = Male; F = Female
21
A
L = Live birth; S = Still birth; A = Abortion
22
A
23
1
24
A
25
A
26a
1 1
26b
A
23 Number of children born from this pregnancy?
24 Is the child living or dead?
25 Where is s/he living now?
26
How old was the child at the time of death?
L = LivingQ25
D = DeadQ26
V = Same Village; A = Agincourt Area;
B = Bushbuckridge Area; E = Elsewhere
(Enter days if < 1 month, enter months if between
1 month and 1 year, enter years if > 1 year)
(Age at death units)
Agincourt Health and Population Unit • PO Box 2 • Acornhoek 1360
tel/fax: 013.795.5076 • email: [email protected]
2012.09.17
D = Days; M = Months; Y = Years
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