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1. Person number ____

You said that -- was in the hospital (nursing home) during the past year.

2. When did -- enter the hospital (nursing home) (the last time)?

Make sure the YEAR is correct

Month ____
Day _ _
Year 19 _ _

3. What is the name and address of this hospital (nursing home)?

Name ____
Street ____
City (or county) ____
State ____

4. How many nights was -- in the hospital (nursing home)?

Nights ____

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?

Nights ____

b. How many of these -- nights were during the past 2 weeks?

Nights ____

c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?

[] Y
[] 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 delivery
[] Normal at birth
Condition ____
Cause ____
Kind ____
Part of body ____

7a. Were any operations performed on -- during this stay in the hospital (nursing home)?

[] Y
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.