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PERSONAL HEALTH EXPENSES
2. In entering the medical expenditures in questions 1 through 3, count all bills paid (or to be paid) by the person himself, his family or friends. Also include 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.
3. In figuring the total doctor, hospital , or dentist bills, 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
Veterans Administration
Federal, State, City or County government
4. 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 meidcal expenditures relating to the baby's health should be reported on the page for the baby.
Please answer the following questions for:
The 12 month period referred to below is from ____ to ____
If exact amounts are not known, please enter your best estimate.
Doctor's Bills
1. How much did all the doctors' (including surgeons) bills for this person come to during the past 12 months?
Operations
Treatments
Check-ups
Deliveries
Pregnancy care
X-rays
Laboratory fees
Eye examinations
Immunizations or shots
Any other doctor's services
Cents ____
[] No doctors' bills
Hospital Bills:
2a. Was this person in a hospital (nursing home, rest home, sanitarium etc) overnight or longer during the past 12 months?
[] No (go to question 3)
b. How much did all of the hospital bills come to for this person for the past 12 months?
Room and board
Operating and delivery room
Anesthesia
Special treatments
X-rays
Tests
Any other hospital services
Cents ____
Dentists' Bills
3. How much did all the dentist's bills for this person come to for the past 12 months?
Fillings
Extractions
Cleanings
X-rays
Bridgework
Dental plates
Straightening of teeth
Any other dental services
Cents ____
[] No dentists' bills
Doctor visits:
4. During the past 12 months, how many times has this person visited or been visited by a medical doctor?
Do not count: 1. Visits to dentists. 2. Any visits made to this person while he was an inpatient for one or more nights in a hospital. (However, please note that the bills for such visits should be included in question 1 above).
[] None