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[p.60]


COSTS FOR MEDICAL AND DENTAL CARE DURING THE PAST 12 MONTHS

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:
Operations
Check-ups
Pregnancy
Laboratory fees
Immunizations or shots
Treatments
Deliveries
X-rays
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
Anesthesia
Special treatments
X rays
Tests
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:
Tonics
Pills
Prescriptions
Salves
Ointments
Vitamins
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:
Fillings
Extractions
Cleanings
X ray
Bridgework
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:

Eyeglasses
[] 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:

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