Identify the medicines shown by the respondent in the medicine list and then record in the corresponding row in the following table. Please complete the table for a maximum of the 3 most used medicines for each condition.
When was the last time you had a pelvic examination? (By pelvic examination, I mean when a doctor or nurse examined your vagina?)
The last time you had the pelvic examination, did you have a PAP smear test? (By PAP smear test, I mean did a doctor or nurse use a swab or stick to wipe from inside your vagina, take a sample and send it to a laboratory?)
In the last 30 days, how much bodily discomfort did you have?
Overall in the last 30 days, how much difficulty did you have with concentrating or remembering things?
In the last 30 days, how much difficulty did you have in learning a new task (for example, learning how to get to a new place, learning a new game, learning a new recipe etc.)?
Overall in the last 30 days, how much difficulty did you have with personal relationship or participation in the community?
In the last 30 days, how much difficulty did you have in dealing with conflicts and tensions with others?
Do you wear glasses or contact lenses?
In the last 30 days, how much difficulty did you have in Seeing and recognizing a person you know across the road (i.e. from a distance of about 20 meters)?
In the last 30 days, how much difficulty did you have in seeing and recognizing an object at arm’s length or in reading?
Overall in the last 30 days, how much of a problem did you have with sleeping, such as falling asleep, waking up frequently during the night or waking up too early in the morning?
In the last 30 days, how much of a problem did you have due to not feeling rested and refreshed during the day?
Overall in the last 30 days, how much of a problem did you have with feeling sad, low or depressed?
Overall in the last 30 days, how much of a problem did you have with worry or anxiety?
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