[p.65]
SURVEY OF FAMILY MEDICAL EXPENSES
Item A
Please list below the names of each family member NOW living at home beginning with the head of the family.
1. ________ ___HEAD___________ [] Male [] Female _______ years old
2. ________ ___________________ [] Male [] Female _______ years old
3. ________ ___________________ [] Male [] Female _______ years old
4. ________ ___________________ [] Male [] Female _______ years old
5. ________ ___________________ [] Male [] Female _______ years old
6. ________ ___________________ [] Male [] Female _______ years old
7. ________ ___________________ [] Male [] Female _______ years old
8. ________ ___________________ [] Male [] Female _______ years old
9. ________ ___________________ [] Male [] Female _______ years old
10. ________ ___________________ [] Male [] Female _______ years old
Are any family members now living at this household on full time active duty with the Armed Forces of the United States?
[] Yes
What is the highest grade or year the HEAD of the family completed in school?
(Circle one)
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 10
[] 11
[] 12
[] 2
[] 3
[] 4
[] 5+
Item B
Besides the family members that you have listed above, is there anyone else living with you now, such as friends or roomers?
(Check one box)
[] Yes
Please list below the name of each person not related to you who is now living at this household. Name of other persons.
2. ________
3. ________
4. ________
5. ________
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The term "this family" in each of the questions on the following pages refers to all members of your family that you have listed in Item A on the page to the left.
Health Insurance
1. During 1970, that is, from January 1, 1970 to December 31, 1970 how much did this family spend on health insurance premiums for plans that pay for any part of a hospital bill or a doctor's bill?
Includes:
Amount deducted from Social Security check for Medicare
Amount paid directly to health insurance plans or to Social Security for Medicare
Do not include:
Employer or union contributions
or
[] This family did not pay any insurance premiums
Payments made for persons not listed in item A on this Questionnaire
2. During 1970, did this family pay any medical expenses for any person who is not listed in Item A on the page to the left?
This might include expenses for children now away at school or parents, other relatives or friends now in nursing homes or elsewhere or who are deceased.
These expenses may include bills from doctors, dentists, optometrists, hospitals, nursing home, health insurance premiums, cost of prescription medicine, eye glasses and so forth.
(check one box)
[] Yes
____ Dollars $ ____ Cents ____
____ Dollars $____ Cents ____
____ Dollars $ ____ Cents ____
____ Dollars $ ____ Cents ____
3. What income group best describes this family's total combined income during 1970?
(check one box)
[] $3000 -$4999
[] $5000-$6999
[] $7000-$9999
[] $10000-$14999
[] $15000-$24999
[] $25000+
4. Please print below the name of the person or persons who are completing this form.
Name ____
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Fill one page for each family member now living in this household write in the person's name below before answering the questions about him:
The following medical and dental expenses were for (write the name of the family member) ________
All questions on this page should be answered even though the person may not have had any medical or dental expenses in 1970. If the person did not have any expense of a certain kind during 1970, be sure to make a mark in the "no bills paid" box. The amounts you give below should only include what this family paid, not any payments made by health insurance or some other person or agency. Do not include payments you made if health insurance has or will reimburse you. If exact amounts are not known, please enter your best estimate.
Dental bills paid
1. How much did this family spend on dental bills for this person during 1970, that is, from January 1, 1970 to December 31,1970?
Cleanings
Fillings
Straightening
X-rays
Dental Surgery
Extractions
Bridgework
Dental laboratory fees
Other services from a dentist or hygienist
or
[] No dental bills paid for this person
Doctor's Bills Paid
2. How much did this family spend on doctor bills for this person during 1970?
Include amounts spent for:
Treatments
Check-ups
Doctor fees while a patient in a hospital
Operations
Deliveries
Pregnancy care
Laboratory fees
Shots
Other services by a medical doctor
or
[] No doctor bills paid for this person
Hospital Bills Paid
3. How much did this family spend on hospital bills for this person during 1970?
Include amounts spent for:
Operating and delivery rooms
Anesthesia
Tests
X-rays
Special treatments
Any other hospitals services
or
[] No hospital bills paid for this person
Payments made for prescription medicine
4. About how much did this family spend on medicine for this person during 1970 that was purchased on a doctor's or dentist's prescription?
Include amounts spent for:
or
[] No prescribed medicines bought for this person
Payments made for eyeglasses, contact lenses or optometrist's bills
5. During1970 how much did this family spend on eyeglasses, contact lenses, or optometrists' fees for this person?
or
[] No amount paid for these items
Payments made for "other" medical bills
6a. How much did this family spend in other medical expenses for this person during 1970?
Include amounts spent for such expenses as:
Chiropractors' or Podiatrists' fees
Hearing aid
Special braces, trusses, wheelchair or artificial limbs
Physical or Speech Therapy
Special nursing care
Nursing Home or Convalescent home care
or
[] No amount paid for these items
6b.What type of medical expense did this person have?
7. Check one of the following boxes
2 [] Referred to records for some but not all dollar amounts entered on this page
3 [] Did not refer to any records