Table II-Hospitalization during past 12 months
[option for 4 entries with the same questions. Only one set is presented here].
c. You said that you were in the hospital (once, twice etc) during the past year--
When did you enter the hospital (the last time)? (enter month, day, and year; if exact date not known, obtain estimate)
d. How many nights were you in the hospital? (if exact number not known accept best estimate)
Complete from entries in columns c and d; or if not clear ask the questions.
e. How many of these --nights were in the past 12 months?
f. How many of these --nights were last week or the week before?
g. Was this person still in the hospital last Sunday night?
h. For what condition did you enter the hospital -do you know the medical name? ________
(if medical name not know, enter respondent's description)
(entry must show "cause" "kind" and "part of body" in same detail as required in table I)
i. Were any operations performed on you during this stay at the hospital?
a. What was the name of the operation? ________
b. Any other operations? ________
j. What is the name and address of the hospital you were in?
(enter full name of hospital, street or highway on which it is located, city and state; if city not known, enter county).
City and State ________
Carry this condition through table I, if it does not appear there and "1" or more nights in col (f). or an impairment or a condition on Card A.
Check list of chronic conditions:
Has anyone in the family had any of these conditions during the past 12 months?
3. Chronic bronchitis
4. Repeated attacks of sinus trouble
5. Rheumatic fever
6. Hardening of the arteries
7. High blood pressure
8. Heart trouble
10. Trouble with varicose veins
11. Hemorrhoids or piles
12. Hay fever
13. Tumor, cyst, or growth
14. Chronic gallbladder or liver trouble
15. Stomach ulcer
16. Any other chronic stomach trouble
17. Kidney stones or chronic kidney trouble
18. Mental illness
19. Arthritis or rhematism
21. Thyroid trouble or goiter
22. Any allergy
24. Chronic nervous trouble
26. Chronic skin trouble
27. Hernia or rupture
28. Prostate trouble
Table A - accidents and injuries
Line no from Table 1: ____
 Accident happened last week or week before (go to Q.3)
1. When did the accident happen?
(if 1961, 1962 or 1963 also enter month): Month ____
2. At the time of the accident, what part of the body was hurt? What kind of injury was it? Anything else?
[option for 3 entries for each : part of body and kind of injury]
Kind of injury (injuries) ____
3. a. Was a car, truck, bus or other motor vehicle involved in the accident in any way?
 No (go to Q.4)
b. Was more than one motor vehicle involved?
c. Was it (either one) moving at the time?
4a. Where did the accident happen--at home or some other place?
2 At home (adjacent premises)
 Some other place
If "some other place", ask:
b. What kind of place was it?
5 Industrial place (include premises)
6 School (includes school premises)
7 Place of recreation and sports, except at school
8 Other (specify the place where accident happened) ________
5. Were you at work at your job or business when the accident happened?
3 While in Armed services
4 Under 17 at time of accidents