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
Year 19 _ _
3. What is the name and address of this hospital (nursing home)?
City (or county) ____
4. How many nights was -- in the hospital (nursing home)?
Complete 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)?
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
 Acc. or Inj.
Part of body ____
7a. Were any operations performed on -- during this stay in the hospital (nursing home)?
0  N (P)
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?
If there is one or more nights in 5b, a Condition page is required.
If there is no Condition page, fill one after completing columns for all required hospitalizations.