Patient---

User---

Contact ID--db-object

Contact---

What is the patient's name?---

Parent---

Household ID---

Parent---

Area ID---

Parent---

Health Facility ID---

Contact---

's Condition---

What is the outcome for the woman?---*

Alive and well---Alive and unwell---Deceased---

This field is required

Postnatal Danger Sign Check - Woman---

Does the woman have any of the following danger signs?---

Fever---*

Yes---No---

This field is required

Severe headache---*

Yes---No---

This field is required

Vaginal bleeding---*

Yes---No---

This field is required

Foul smelling vaginal discharge---*

Yes---No---

This field is required

Convulsions---*

Yes---No---

This field is required

Death Information - Woman---

Date of death---*Date cannot be in the future and older than a month from today.---This field is required

What was the place of death?---*

Health facility---Home---Other---

This field is required

Did the woman deliver any babies before she died?---*

Yes---No---

This field is required

Additional notes---300 characters---After reporting a death, the person's profile will be locked. If reported in error, you may undo the death report from the profile.---If babies were delivered, you will have the chance to report on them Next >.---

-selected(../../condition/woman_outcome, 'deceased')hidden

Delivery Outcome---

How many babies were delivered?---*

1---2---3---Other---

This field is required

*Select this only if more than 3 babies were delivered.---This field is required

How many babies are alive?---*

0---1---2---3---Other---

This field is required

*Can not be more than babies delivered.---This field is requiredDate of delivery---*Date cannot be in the future and older than a month from today.---This field is required

Where did delivery take place?---*

Health facility---Home---Other---

This field is required

Please specify other---*Maximum 100 characters allowed.---This field is required

How did she deliver?---*

Vaginal---Cesarean---

This field is required

Who conducted the delivery?---*

Skilled health care provider---Traditional birth attendant---Other---

This field is required

Please specify other---*Maximum 100 characters allowed.---This field is required

Death Information - Baby---

---

Date of death---*Date cannot be in the future and older than a month from today.---This field is required

Place of death---*

Health facility---Home---Other---

This field is required

Was this a stillbirth?---*

Yes---No---

This field is required

Additional notes about baby's death---300 characters---

--hidden

Baby's Condition---

Sections will repeat if multiple babies were delivered. Please fill out one section per baby.---

Safe Postnatal Practices---

Lactating mothers need to eat more than usual to feed their baby well. Ask the woman to eat a variety of foods, especially extra fluids, fruits, and vegetables.---For the first 6 months, give the baby breastmilk only.---To keep the baby warm, use kangaroo mother care, wrap the baby with clothes and cover the head, and keep the baby in a warm room.---Always sleep with the baby under a long-lasting insecticide treated net (LLIN).---Keep the baby's umbilical cord clean and dry.---

PNC Visits---

The WHO recommends PNC visits within 24 hours and on 3 days, 7 days, and 6 weeks from date of delivery.---

Which PNC visits have taken place so far?---*

Within 24 hours (check this box if facility delivery)---3 days---7 days---6 weeks---None of the above---

Value not allowedThis field is required

Any additional PNC visits, please report the number of visits below to be counted in the total.---Must be between 0 and 6.---