SURVEY FORM – RISK FACTORS AND STRATEGIES FOR PREVENTION OF PRETERM BIRTH

This is the questionnaire that deals with risk factors and strategies for prevention of preterm birth.
Please take a few minutes to express your opinions about the availability and quality of health care
in your community regarding preterm birth. Your answers are important to the success of this study.

1. Name and address of the Patients (Mother’s Name)

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2. Age
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3. How much did your child weigh at birth?

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4. When your child was born, was he/she very small, smaller than average, average, larger than
average, very large?

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5. Do you have a birth record or certificate with your child’s birth weight recorded?

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6. When your child was born, was he/she born very early, early, on time, late, or very late?

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7. At where you was hospitalized?

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8. Do you have a preferred hospital?

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9. Is there a difference in performance between the available hospitals in this area?

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10. Overall support from the hospital

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Thank you for your assistance.