USE YOUR CALENDAR
Make sure the YEAR is correct
Year 19 _ _
City (or county) ____
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 ____
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 the condition in 6 or 7 is listed specifically in 31A, B, or 32, 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.