[p.66]
HOSPITAL PAGE
You said that -- was in the hospital (nursing home) during the past year.
2. When did -- enter the hospital (nursing home) (the last time)?
USE YOUR CALENDAR
Make sure the YEAR is correct
Day _ _
Year 19 _ _
3. What is the name and address of this hospital (nursing home)?
Street ____
City (or county) ____
State ____
4. How many nights was -- in the hospital (nursing home)?
Complete question 5 from entries in questions 2 and 4; if not clear, ask the questions.
5a. How many of these -- nights were during the past 12 months?
b. How many of these -- nights were during the past 2 weeks?
c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?
[] N
[p. 67]
6. For what condition did -- enter the hospital (nursing home) - do you know the medical name? If medical name unknown, enter an adequate description.
For delivery, ask: Was this a normal delivery?
For newborn, ask: Was the baby normal at birth?
If "No," ask: What was the matter?
Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.
[] Normal at birth
Condition ____
Cause ____
Kind ____
Part of body ____
7a. Were any operations performed on -- during this stay in the hospital (nursing home)?
0 [] N (8)
b. What was the name of the operation? If name of operation is not known, describe
what was done. ________
c. Any other operations during this stay?
[] Y (Describe) ________
[] N
8. NOTE: If the condition in Q. 6 or 7 is in Q. 36 and is NOW present or there is "1" or more nights in Q. 5b, a Condition page is required. If there is no Condition page, fill one after completing columns for all required hospitalizations.