Questionnaire Serial # 1. 3. 4. 5. 6. Name: Age: Qualification: Occupation: Occupation of husband: Ref # Date: 2.

Husband name:

7. Family system: Joint 8. No of dependents: 9. Socioeconomic status: >10,000 10,000-50,000 <50,000 10. Area: Urban 11. Physical examination: Weight: Height: Blood pressure: Pulse: 12. History: No of pregnancy: No of week: History of miscarriage: History of still births: Time interval b/w two pregnancies: Congenital syndrome: Extra endocrinal syndrome: Diabetes/ gestational diabetes: Yes Others: Hepatitis: Yes Depression: Yes Hypertension: Yes Gestational hypertension: Yes Eclampsia/ pre-eclampsia: Yes 13. Dietary habits: Vegetarian Consumption of protein: Content of fat: High High

Isolated

Rural BMI:

No No No No No No Non-vegetarian Average Average Uncooked No No (If yes: No (If yes: ) ) Low Low

Consumption of vegetables: Cocked Consumption of fruits: 14. Smoker/ passive smoker: Yes 15. Drug history: Corticosteroids: Yes Contraceptive pills: Yes

Weight losing drugs: Lipid lowering drugs: Statins: Supplements: Antidepressants: 16. Physical activity (exercise): 17. Life style: House wife: Working 18. Biochemical parameters: a. Blood sugar: b. Cholesterol: c. TAG (Tg): d. HDL: e. LDL: f. VLDL:

Yes Yes Yes Yes Yes Yes Self-working

No No No No No No

(If yes: (If yes: (If yes: (If yes: (If yes:

) ) ) ) )

Maid