Are you filling for others

1. State

2. District

3. Pincode

4. Type of Area

6. Date of Survey

1. Name of Mother

2. Present Age of Mother (in years)

3. Educational qualification of Mother

4. Height of the Mother (cm)

5. Weight of the Mother (kg)

1. Name of the Index Child:

2. Date of Birth

3. Age (in completed months):

4. Sex

1. Boy 2. Girl

5. Child Birth Weight

6. Child Birth order

7. Current Height of the Child (cm)

8. Current Weight of the Child (kg):

1.Did you registered for ANC check up during the last pregnancy

8. Have you received ICDS supplements during pregnancy?

9. Type of Delivery

10. Place of Delivery

11. Preterm Birth (Born before 9 months)