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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.




General instructions:

1. The name of each related member of the household has been entered on a separate page of this form. Pleae fill all sections of each page for each person listed
2. The specific period we are asking about is the 12 months period from ____ to ____
3. In entering the total medical expenditures, count all bills paid (or to be paid) by the person himself, his family or friends and also any part paid by insurance, whether paid directly to the hospital or doctor, or paid to the person himself, or to his family. If you do not know exactly the amount paid by insurance, estimate it, and include it in the total bill.
4. Please do not count any amounts paid (or to be paid) by:
Workmen's compensation
Non-profit organizations such as the "polio foundation"
Charitable or Welfare organizations
Military services, including medicare
Veterans administration
Federal, state, city or county government
5. If there are any babies in the household who were born during the past 12 months, the hospital and doctor bills relating to the baby's birth should be reported on the page for the mother. All other medical expenditures relating to the baby's health should be reported on the page for the baby.
6. After completing all sections of this form for each person in the household, please indicate below the name of the person or persons who filled it out.
Name ________
Name ________

Please answer the questions in each section below for:

Name of person:________

If exact amounts are not known, please enter your best estimate.
Doctor's bills
1. How much did all of the doctors' (including surgeons') bills for this person come to during the past 12 months?

Be sure to count all doctor's bills for:
Laboratory fees
Immunizations or shots
Eye examinations
Any other doctor's services
[] No doctor's bills

Hospital bills

2.a. Was this person in a hospital (nursing home, rest home, sanitarium , etc) overnight or longer during the past 12 months?

[] Yes (b)
[] No (go to questions 3)

b. How much did all of the hospital bills come to for this person for the past 12 months?

Be sure to count all hospital bills for:
Room and board
Operating and delivery room
Special treatments
X rays
Any other hospital services
$ ________

Medicine costs
3. About how much was spent for medicine for this person during the past 12 months?

Be sure to count costs for all kinds of medicine whether or not prescribed by a doctor, such as:
Any other medicine
[] No costs for medicine

Dentists' bills
4. How much did all the dentists' bills for this person come to for the past 12 months?

Be sure to count all dental bills for:
X ray
Dental plates
Straightening of teeth
Any other dental services
[] No dentists' bills

Special medical expenses
5. How much did the bills come to for this person during the past 12 months for:

[] None
Special nursing, physical therapy, speech therapy?
[] None
Chiropractors' fees?
[] None
Hearing aids?
[] None
Corrective shoes?
[] None
Special braces or trusses, wheels chairs or artificial limbs?
[] None

Other medical expenses
6. Enter any other medical expenses incurred during the past 12 months which are not included above, showing the kind and amount of expenditure (for example, emergency or outpatient treatment in a hospital or clinic). (if no other medical expenses, check the "None" box).

[] None
Kind ________

For office use only:

PSU.No ____
Segment No ____
Serial no ____
Column no ____