Survey sample

 TREATMENTS USED FOR: (local name of the problem)

· Illness description (in basic English):

· First treatments (the last time the problem has come out in the family):
___ traditional medicinal plants
___ healer or witch doctor
___ medical officer

· Description and way of preparation of the remedy:

· How did you take the remedy, in what quantity and how many times?:

· Where did you find the plants?
___ yard
___ not at home

· Have you already used this remedy?
___ Yes
___  No

· Which results have you obtained?

· What precautions should be observed during treatment?
(contraindications & side effects)

· And for the children?
(contraindications and directions for use)