Case Identifier/Registration Number:
Name: Date of birth:
Address:
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Do you know you can pass HIV on to your baby through breast feeding?
Do you know your baby is more likely to get diarrhoea or malnutrition when you do not prepare formula feeds
correctly or hygienically?
Do you know that the risk of passing HIV on to your baby is ‘four times’ higher when you mix feed (i.e.
breastfeeding and formula feeds) than breastfeeding only?
Do you know that you stand the chance of getting pregnant soon if you choose not to breastfeed or use
contraceptives?
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1 Would you be able to carry on with your choice of feeding (breastfeeding or formula feeding)
even in the presence of pressure to change from family and friends?
2 Does the father of your child know your HIV status?
3 Do the people close to you know your HIV status?
4 If you choose to formula feed, would you be comfortable giving infant formula in
public/community?
5 Can you prepare formula feed and feed your baby every 2-4 hrs (6-12x/day) day and night for up
to six months?
6 Do you have anybody that could help you to prepare and feed your baby whenever you are not
available?
7 Do you have a source of clean water or tap water in your home/compound or close by?
8 Do you have a refrigerator in your home?
9 Do you have constant supply of electricity?
10 Would be able to ensure constant supply of formula milk?
11 When needed, will you be able to buy formula milk in a neighbourhood shop?
12 Can you afford $... (Amount varies for different countries) on infant formula for at least six
months without affecting the health and nutrition of other family members?
13 Can you afford $... (Amount varies for different countries) on utensils and cooking fuel required
for preparing infant formula for at least six months?
14 Do you have a source of regular income?
15 Does the father of your child have a source of regular income?
16 Would you always remember to wash your hands with clean water after using the toilet and
before preparing formula feeds
17 Would you be able to wash with clean water all utensils required for preparing formula feeds?
18 Is there a health facility that provides Maternal and Child health services that you can go to if
your baby need medical attention?
TOTAL NUMBER OF YES RESPONSES
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