Form Genoe-F03 - Client Service Receipt Inventory Form printable pdf download

Form Genoe-F03 - Client Service Receipt Inventory Form

GENOE-F03

Client Service Receipt In ventory Form

Short Form (BADS-SF)

Trial ID:

CSRI Part A

Instruc on: I am now going to ask you ques ons about all the diﬀerent types of services you have used

for health care in the past 3 months..

** Exclude cost of medicines

or inves ga ons

* If own transport

Have you had contact with any of these health services in the last

record kms.: ________

3 months?

0=No

Number of

Avg. me

Health

Was there

Avg. amt. of money

Avg. me

Avg. fee

1=Yes

contacts in

care

spent on travelling

wai ng

to travel

spent with

per

If YES, ASK

past 3

providers

(Return) *

to be

accompanying

(round

provider

visit**

FURTHER

for Pa ent and

months

seen (in

person?

trip in

(in minutes)

QUESTIONS

Accompanying

minutes)

1 = Yes

person'

0 = No

1.1

PHC

doctor

1.2

Hosp. doc

(Public Dr.)

DHS or

GMC

Private

1.3

Doctor

Tradi onal

1.4

Healer

Detoxi?ca on

1.5

services at

IPHB, Asilo

or Private

Hospital or AA

(for HD trial

par cipant t s

only)

Probe as indicated

Reason for

All costs

Have you been

Type of hospital:

Number of

1 = Yes

below on whether

admission

(include

Private=1

nights spent

admi ed to a

0 = No

admission was

travel)

Public=2

hospital, i.e. spent

planned (1) or

at least one night

unplanned (2)

in hospital,

as instructed below

in the

last 9 months

2.1

Admission 1:

Rs.

Admission 2:

2.2

Rs.

Admission 3:

2.3

Rs.

List Detoxi?ca on

Rs.

2.4

admissions

separately

for drinkers

Form Genoe-F03 - Client Service Receipt Inventory Form

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