ID no: ___________ MH/CMH: ________

Proforma of Knowledge and practice regarding folic acid in women patients visiting Military and Combined Military hospital Rawalpindi.
This questionnaire is made simply to assess the Knowledge and practice regarding folic acid in women patients visiting Military hospital Rawalpindi and does not require any personal identity of the one answering this Performa.
1. Age: _______years. 2. Education: a. Illiterate b. Primary c. Secondary d. Higher secondary e. Graduation 3. How many Children do you have? a. Zero b. 1 c. 2 d. More than 2 4. Is there any history of abortion or still birth? a. No b. 1 c. 2 d. Multiple 5. Is there any history of giving birth to a child with low birth weight? a. Yes b. No 6. Is there any history of giving birth to a child with defect/s? a. Yes b. No 7. Has any Physician/Gynecologist told you about importance of Folic acid? a. Yes b. No 8. Have you ever heard about Folic acid use from your parents, friends or relatives? a. Yes b. No 9. Have you ever heard about folic acid use and its importance from media? a. Yes b. No 10. Do you know there is a need for pre- pregnancy Folic Acid Supplementation? a. Yes b. No 11. Do you know there is a need for Folic Acid Supplementation during first three months of pregnancy? a. Yes b. No 12. Did you receive Folic acid supplementation during your previous pregnancy/cies? a. Yes b. No c. May be d. Dont know 13. Do you think it is important for women of child bearing age to know about folic acid? a. Yes b. No c. Maybe d. Dont know 14. Folic acid deficiency in pregnant lady results in abnormality in baby? a. Yes b. No c. Dont know 15. Which of the following is rich source of Folic acid? a. Green leafy vegetables b. Meat, eggs and dairy products c. Cereals d. Supplementations/Medications e. Dont Know 16. Nutritious value of food declines due to excessive cooking? a. Yes b. No c. Dont know 17. Your daily meals mostly consist of? a. Vegetables and fruits b. Meat and dairy products c. Junk food d. Both meat and vegetables 18. Do you think folic acid supplementations are harmful for health? a. Yes b. No c. Dont know 19. Is birth defects due to Folic acid deficiency are emerging health problem in our society? a. Yes b. No c. Dont know 20. Do you want to attend educational lectures or workshop on folic acid supplementation? a. Yes b. No c. Maybe