Form Genoe-F03 - Client Service Receipt Inventory Form Page 4
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4GENOE-F03
Client Service Receipt Inventory Form
Short Form (BADS-SF)
1 Yes
In the last 3 months, have you taken tablets,
8
medicines or injec ons?
0 No
Type:
If yes,
Quan
Dosage
Cost of Drugs
8.1
Consump
1 Paid
1 Tablet
Name/
bought/given
(i.e.,
(if available:
past 3 months
2 Syrup
0 Free
Descrip on
e.g. 1 Bo
strength of
total cost of
3 Injec ons
No. of
Per day
of drug
1 strip of 10 tablets
medica
last 3 months)
4 Ointment
e.g.
Days
(last 3 months)
in mg/ml, etc.)
5 Spray
tablets/
6 Drops
teaspoons
7 Powder
8 Others
(Specify)
TOTAL
INTERVIEWER NOTE: The aim of this table is to list all medicines and the dura on taken so that the amount of
rupees can be calculated; however, if the subject is unaware of these details, the total amount of money spent in
the past 3 months can also be entered in the Total Box. A subject may only know how much is spent each week;
in this case, mul ply the weekly cost by 12 to get the 3 - month total)
WHERE AVAILABLE, AND WITH THE PATIENT'S PERMISSION, TAKE A PHOTO OF THE PRESCRIPTION
DESCRIBING THE MEDICINES
Ques ons about Sigma sa on
Instruc on: Now I would like to ask a few ?nal ques ons about your experiences in last 9 months.
9. In last 9 months did you feel uncomfortable or worried because you thought other
1 Yes
people might ?nd out about your problem, make nega ve comments
0 No
or treat you di?erently?
1 Yes
10. In last 9 months did your family members feel uncomfortable or worried because they
thought other people might ?nd out about your problem, make nega ve
0 No
comments or treat you di?erently?
(To be asked only to HD patients)
Readiness to change
How ready are you to make change in your drinking?
1. Not at all
2. A little ready
3. Ready/not ready equally
4. Moderately ready
6.Already made a change
5. Already trying to change
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Parent category: Business