[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
BB. A strain or sprain? ____
CC. A burn or scald? ____
DD. A concussion or other head injury? ____
EE. A dislocation or a broken bone? ____
FF. A gunshot wound? ____
GG. An injury due to suffocation? ____
HH. An injury due to electric shock? ____
II. An animal bite? ____
JJ. A reaction to medication or cosmetics? ____
KK. Any poisoning from swallowing, breathing, or coming in contact with a poisonous substance? ____
LL. Any injury to the teeth, mouth, or jaws? ____
MM. Any injury to the neck, back, or spine? ____
NN. Any injury to the eyes, ears, or nose? ____
OO. ____
PP. ____
QQ. ____
RR. ____
2a. Since (date), did -- have any (other) injuries (besides [conditions A-RR])?
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.
[] 1+ accidents circled in Item C and entered in Table I
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.