COSTS FOR MEDICAL AND DENTAL CARE DURING THE PAST 12 MONTHS
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:
Non-profit organizations such as the "polio foundation"
Charitable or Welfare organizations
Military services, including medicare
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.
Immunizations or shots
Any other doctor's services
 No (go to questions 3)
Room and board
Operating and delivery room
Any other hospital services
Any other medicine
Straightening of teeth
Any other dental services
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).
Segment No ____
Serial no ____
Column no ____