Geographic data | |
Distance between home and centre: | |
0–5 km - between 5 and 20 km - between 20 and 50 km - over 50 km | |
Duration of travel (hours, minutes) from home to the centre (Hour, minutes): | |
Family characteristics | |
Language spoken in the family of the child or adult patient: | |
Marital status of the patient or parent responding to the survey: | |
Number of children living in the home: | |
Siblings with cystic fibrosis (number of children): … | |
Other medical conditions in the family (name the condition): …………. | |
Socio-professional characteristics | |
Employment status of the patient or parent responding to the survey: | |
- Salaried worker | - no professional activity |
- Self-employed | - on disability benefits |
- Student | - retired |
Socio-professional category of the patient or parent responding to the survey: | |
- Farmer or farm operator | intermediate profession |
- Craftsman or trader | - employee |
- Executive or intellectual profession | - worker |
- Student | |
Education level of the patient or parent responding to the survey: | |
- No diploma | - undergraduate degree |
- French certificate of general education | - master's degree |
- French vocational qualifications (CAP-BEP) | - PhD level |
- French general baccalaureate or professional baccalaureate | |
Specific criteria | |
- Activities with associations | - other: |