Health Impact study

Health Impact study :
1.Name: 2. Designation: 3. Address of the House:

4 BMI: 5 Height 6 Weight. .7 PF(l/min)

ID code Responded code-1,
Husband-2,
Wife-3,
First child-4,
Second child-5,
Third Child-6,
Fourth Child-7,
Others-8
No of Family Members
Code-1,
Code-2,
Code-3,
Code-4,
Code-5,
Code-6,
Code-7,
Code-8 No Code Male-1
Female-2 Married code-1,

Unmarried code-2 Primary-1-5
Secondary/SSC-5-9
More/Others-11
No Education-14 Income sources-1
For Job-2
Working in Brick field-3
Family shifting-4
Land less-5
By birth-6
Others Work or lived in Brick Field Area
Respondent and relationship to Respondent Family Members Age Sex Marital Status Education Reason for work or live in brick field Area No Code

8. House Construction materials/Living condition:
Wood and Bamboo Tin Shade Mix(Bamboo/tin) Brick/Building Semi Building Others

8b. Cooking conditions:
– what kind of stove do you use? (wood fired, charcoal, gas, electricity)
– do you do the cooking indoor or outdoor?
– how many hours per day do you (yourself) spend cooking (on average)?
9. Do you Smoke? Yes-1, No-2, Ex-amoker-3 1 ? 2 ? 3 ? 10. Name of Disease