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[p. 66]


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 ____
Date ____
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 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

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 ____
[] On Card C
[] Acc. or Inj.
Kind ____
Part of body ____

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

[] Y
0 [] N (P2)

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


If the condition in 6 or 7 is in 31 or there is "1" or more nights in 5b, a Condition page is required. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required hospitalizations.