Did the deceased report / experience chest pain lasting less than 24 hrs in the month preceding the death?
Did the deceased experience paralysis of any part of the body in the month preceding death?
If yes, was the paralysis accompanied or followed by sudden loss of consciousness?
Did the deceased have a cough that lasted more than 3 weeks?
If yes, was there blood in the sputum ?
Did (s)he receive any medical treatment for tuberculosis ?
Did the deceased have diarrhoea that lasted more than a month ?
Was there any rapid loss of weight ?
Were there any white patches in the mouth ?
Overall in the last 30 days, how much difficulty did [name of person] have with self-care, such as washing or dressing himself/herself?
In the last 30 days, how much difficulty did [name of person] have in taking care of and maintaining his/her general appearance(e.g. grooming, looking neat and tidy etc.)
Overall in the last 30 days overall how much difficulty did [name of the person] have with concentrating or remembering things?
In the last 30 days, how much difficulty did [name of person] 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 [name of person] have with self-care, such as washing or dressing himself/herself?
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