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General instructions

1. The name of each related member of the household has been entered on a separate page of this form. Please fill the 4 questions on each page for each person listed. If you cannot give the exact amount from bills or records please enter the best estimate you can.
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:

Name of person ________

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?

Be sure to count all doctors' bills for:
Pregnancy care
Laboratory fees
Eye examinations
Immunizations or shots
Any other doctor's services
Dollars $____
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?

[] Yes
[] No (go to question 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
Any other hospital services
Dollars $____
Cents ____

Dentists' Bills

3. How much did all the dentist's bills for this person come to for the past 12 months?

Be sure to count all dental bills for:
Dental plates
Straightening of teeth
Any other dental services
Dollars $____
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?

Count: 1. All visits to a doctor's office or clinic for consultation, shots, X-rays or for any other medical purpose. 2. All doctor visits made to the home.
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).
Doctor visits ____
[] None

5. Name of person completing this page ________

Comments: ________