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4S.N
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DEMOGRAPHIC PROFILE
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Case/Control
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1=Case
2=Control
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Gender
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1= Male
2= Female
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Age
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Put the years
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Marital Status
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1= Married (M)
2= Single (U)
3=Married but separated now (S)
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Ethnicity
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1=Brahmin
2=Chhetri
3=Newar
4=Dalits
5=Janajati
6=Madhesi
7=Others (Please note it down)
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Body Mass Index
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1. Height in Feet
2. Weight in Kg
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Rural or Urban
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1. Rural
2. Urban
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Religion
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1=Hindu
2=Buddhist
3=Muslim
4=Christian
5=Sikh
6=Others (Please note it down)
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History of Cancer in Family
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1=Yes
2=No
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Education
Ever attended School
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1=No
2=No, but I can read and write
3=Yes
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Years of Formal Education
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Put the number of years
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Level of your education
When case/control has filled something in others section, please note down what they have written, as it might also be important information.
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1=No Formal Schooling
2=Less than Elementary/Primary School
3=Primary School Completed
4=Less than Secondary School
5=Secondary School completed
6=High School Completed
7=College/University Completed
8=others/don’t know
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Socioeconomic Score
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Please add all three (ABC) scores
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Socioeconomic Status
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1=Low (If Score is (6 to 7)
2=Medium (if score is 5)
3=High (If score is 3 to 4)
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Occupation
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1=Student
2=Full-time work
3=Part-time/ casual work
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Income/Month
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Smoking Habits
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Smoking Status
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1=Current smoker
2=Ex-smoker
3=Non-smoker
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Cigarettes Type
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1. Filter
2. Non-Filter
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How long have you been smoking?
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1=Less than 6 months
2=6 months
3=1 – 3 years
4=4 – 6 years
5=7 – 10 years
6=More than 10 years
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Anyone Smoker at Home
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1=Yes
2=No
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CHEWING HABITS
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Chewing Status
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1=Chewing Currently
2=Chewed in the Past
3=No Chewing Habits
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Types of Product Used
What types of Chewing tobacco products you used in the past or at present?
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1=Paan with tobacco (Zarda Paan)
2=Paan without tobacco (Mitha Paan)
3=Khaini (Moist or wet tobacco)
4=Gutkha
5=Zarda
6=Surti
7=Pan Masala
8=Gul (Tobacco toothpaste)
9=Snuff (Tobacco intake by nose)
10=Supari
11=Others (please specify………………….)
(Note if the respondent use more than 1 product please specify each)
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Alcohol Drinking Habits
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1=Drink Alcohol currently
2=Drunk in the Past
3=No Drinking Habits
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Types of Alcohol product
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1=Raksi
2=Jaand/Chyang
3=Thongba
4=Beer
5=Wine
6=Hard Liquor (Whisky, Rum, Vodka, Gin)
7=Other (specify)
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Quantity of Alcohol
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For Beer (Indicate the number of bottles)
For Whisky (indicate, quarter, half, full)
For Local Alcohol Beverages (Small glass, medium glass, Large glass)
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