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accd

[p. 67]

INJURY PAGE

These next questions are about accidents and injuries that caused anyone in the family to see or talk to a doctor OR cut down on the things they usually do for as much as a day.

1a. Since (date), did you, your --, etc., have -

If "Yes," ask:

b. Who was this? (Circle "Y" in this person's column.)

c. Since _____ (date), how many different accidents resulting in . . . did -- have that caused him to see or talk to a doctor OR cut down on the things he usually does?

d. Since _____ (date), did anyone else have . . . ?

(If "Yes," reask 1b-d.)

Table I

AA. A cut or bruise? ____

Had injury
[] Y
Number of accidents ____

BB. A strain or sprain? ____

Had injury
[] Y
Number of accidents ____

CC. A burn or scald? ____

Had injury
[] Y
Number of accidents ____

DD. A concussion or other head injury? ____

Had injury
[] Y
Number of accidents ____

EE. A dislocation or a broken bone? ____

Had injury
[] Y
Number of accidents ____

FF. A gunshot wound? ____

Had injury
[] Y
Number of accidents ____

GG. An injury due to suffocation? ____

Had injury
[] Y
Number of accidents ____

HH. An injury due to electric shock? ____

Had injury
[] Y
Number of accidents ____

II. An animal bite? ____

Had injury
[] Y
Number of accidents ____

JJ. A reaction to medication or cosmetics? ____

Had injury
[] Y
Number of accidents ____

KK. Any poisoning from swallowing, breathing, or coming in contact with a poisonous substance? ____

Had injury
[] Y
Number of accidents ____

LL. Any injury to the teeth, mouth, or jaws? ____

Had injury
[] Y
Number of accidents ____

MM. Any injury to the neck, back, or spine? ____

Had injury
[] Y
Number of accidents ____

NN. Any injury to the eyes, ears, or nose? ____

Had injury
[] Y
Number of accidents ____

OO. ____

Had injury
[] Y
Number of accidents ____

PP. ____

Had injury
[] Y
Number of accidents ____

QQ. ____

Had injury
[] Y
Number of accidents ____

RR. ____

Had injury
[] Y
Number of accidents ____

2a. Since (date), did -- have any (other) injuries (besides [conditions A-RR])?

1 [] Y
2 [] N (A)

b. What type of injury did he have? (Ask 1c, THEN reask 2a) ____

A
Verify that all accidents circled in item C are represented in Table I.

[] No accidents circled in Item C
[] 1+ accidents circled in Item C and entered in Table I
B
0 [] No injuries in I (NP)
1 [] One injury in I (Enter number of accidents in 3, then NP)
2 [] 2+ injuries in I (3)

NOTE: Fill Accident Supplement column for each accident.