Health 3. Address of the House: 4

Health Impact study :1.Name: 2. Designation: 3. Address of the House:4 BMI: 5 Height 6 Weight. .

7 PF(l/min)ID code Responded code-1,Husband-2,Wife-3,First child-4,Second child-5,Third Child-6,Fourth Child-7,Others-8 No of Family MembersCode-1,Code-2,Code-3,Code-4,Code-5,Code-6,Code-7,Code-8 No Code Male-1Female-2 Married code-1,Unmarried code-2 Primary-1-5Secondary/SSC-5-9More/Others-11No Education-14 Income sources-1For Job-2Working in Brick field-3Family shifting-4Land less-5By birth-6Others Work or lived in Brick Field Area Respondent and relationship to Respondent Family Members Age Sex Marital Status Education Reason for work or live in brick field Area No Code 8. House Construction materials/Living condition:Wood and Bamboo Tin Shade Mix(Bamboo/tin) Brick/Building Semi Building Others 8b. Cooking conditions: – what kind of stove do you use? (wood fired, charcoal, gas, electricity) – do you do the cooking indoor or outdoor? – how many hours per day do you (yourself) spend cooking (on average)?9. Do you Smoke? Yes-1, No-2, Ex-amoker-3 1 ? 2 ? 3 ? 10. Name of Disease

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