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A planned IPUMS system update is scheduled for Monday, December 9. The maintenance window is 10am to 1pm CST. Within that window, each site will have a brief outage of 10 or fewer minutes. This notice will be removed as soon as the update is complete.



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U.S Department of Health, Education, and Welfare
Public Health Service
Hyattsville, Maryland 20782
National Center for Health Statistics

Dear Friend:

Your household has just taken part in a health interview conducted by the Bureau of the Census for the US Public Health Service. We greatly appreciate your cooperation in providing us with this information.

Another area of great concern today is the cost of health care in our country. We, therefore, ask you to provide us with information about the amount of money you, your family, and other relatives living with you spent for medical care during the past 12 months, that is, from January 1, 1977 to December 31, 1977 by answering the few questions on this form. Please use any records such as bills, receipts, or check stubs, that would help you in answering the questions. If you cannot supply the exact amounts from your records, give the best estimate you can.

We would appreciate your completing the attached questionnaire within FIVE DAYS, and returning it in the enclosed preaddressed envelope which requires no postage. If a delay cannot be avoided and you cannot answer and return your form during this time, please fill in the information and return it as soon as possible. Since this study is based on a scientific sample of the total population, it is important that each household return a completed questionnaire.

Please be assured that the Bureau of the Census and US Public Health Service hold as confidential all the information you provide. Thus, the results of this voluntary survey will be issued only in the form of statistical totals from which no individual can be identified.

Thank you for your cooperation.
Sincerely yours
Robert R Fuchsberg
Director
Division of Health Interview Statistics

Assurance of Confidentiality: Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study and will not be disclosed or released to others without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m).

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GENERAL INSTRUCTIONS

1.Fill a separate page for the family member whose name is entered at the top. Answer all questions on the page even though the person may not have had any medical or dental expenses during the past 12 months. If the person did not have any expense of a certain kind during that period, mark the "No bills paid" box. The amounts you give should only include what THIS FAMILY paid, NOT any payments made by health insurance or some other person or agency. IF EXACT AMOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE.

2. Do NOT include any amounts paid (or to be paid) by:

Health insurance
Workman's compensation
Non-profit organizations such as the "Polio Foundation"
Charitable or Welfare Organizations
Military Services
Veterans Administration
Federal, State, City, or County Governments

3. If there are any babies in the household who were born during the past 12 months, the hospital and doctor bills relating to the baby's birth should be reported on the page for the mother. All other medical expenditures relating to the baby's health should be reported on the page for the baby.

4. PLEASE COMPLETE THE BACK PAGE BEFORE MAILING.

Please answer the following questions for _______________ Person No. ____


DENTAL BILLS PAID

1. How much did THIS FAMILY spend on dental bills for this person during the past 12 months, that is, from January 31, 1977 to December 31, 1977?

Include amounts spent for: Cleanings, Fillings, Straightening, X-rays, Dental surgery, Extractions, Bridgework, Dental laboratory fees, Other services from a dentist or hygienist

Dollars $___ Cents ___
or
No dental bills paid for this person _______


DOCTORS' BILLS PAID

2. How much did THIS FAMILY spend on doctor bills for this person during the past 12 months?

Include amounts spent for: Routine doctor visits, Treatments, Check-ups, Doctor fees while a patient in a hospital, Operations, Deliveries, Pregnancy care, Laboratory fees, Shots, Other services by a medical doctor

Dollars $___ Cents ___
or
No doctor bills paid for this person _______


HOSPITAL BILLS PAID

3. How much did THIS FAMILY spend on hospital bills for this person during the past 12 months?

Include amounts spent for: Room and board, operating and delivery rooms, Anesthesia, Tests, X-rays, Special treatments, Any other hospital services

Dollars $___ Cents ___
or
No hospital bills paid for this person _______


PAYMENTS MADE FOR PRESCRIPTION MEDICINE

4. During the past 12 months, how much did THIS FAMILY spend on medicine for this person during the past 12 months that was purchased on a DOCTOR'S OR DENTIST'S PRESCRIPTION?

INCLUDE amounts spent for: Medicines ONLY if they were prescribed by a doctor or dentist

Dollars $___ Cents ___
or
No prescribed medicines bought for this person _______


PAYMENTS MADE FOR EYEGLASSES, CONTACT LENSES, OR OPTOMETRIST'S BILLS

5. During the past 12 months, how much did THIS FAMILY spend on eyeglasses, contact lenses, or optometrists' fees for this person?

Dollars $___ Cents ___
or
No amount paid for these items _______


PAYMENTS MADE FOR "OTHER" MEDICAL BILLS

6a. How much did THIS FAMILY spend on other medical expenses for this person during the past 12 months?

DO NOT INCLUDE any expenses which you have already recorded. DO NOT INCLUDE amounts spent for medicines of any kind.

INCLUDE amounts spent for such expenses as: Chiropractors' or Podiatrists' fees, Hearing aid, Special braces, trusses, wheelchair, or artificial limbs, Physical or Speech Therapy, Special nursing care, Nursing Home or Convalescent Home care

Dollars $___ Cents ___
or
No amount paid for these items _______


6b. What type of medical expenses did this person have?

Type of Medical Expenses _______________

REFERRED TO RECORDS


7. Check one of the following boxes:

1. Referred to records for ALL dollar amounts entered on this page.
2. Referred to records for SOME but not all dollar amounts entered on this page.
3. Did NOT refer to any records.


HEALTH INSURANCE

1, During the past 12 months, that is, from January 1, 1977 to December 31, 1977 how much did THIS FAMILY spend on health insurance premiums for plans that pay any part of a hospital bill or doctor's bill?

INCLUDE:
Amount deducted from paycheck for health insurance premiums
Amount deducted from Social Security check for Medicare
Amount paid directly to health insurance plans or to Social Security for Medicare
DO NOT INCLUDE:
Health insurance plans that pay only in the case of accidents
Employer or union contributions
Dollars $___ Cents ___
or
This family did not pay any insurance premiums _______


PAYMENTS MADE FOR PERSONS NOT LISTED ON THIS QUESTIONNAIRE

2. During the past 12 months, that is, from January 1, 1977 to December 31, 1977 did THIS FAMILY pay any medical expenses for anyone whose name does NOT appear on this questionnaire?

This might include expenses for children now away at school or parents, other relatives or friends now in nursing homes or elsewhere, or who are deceased.

These expenses may include bills from doctors, dentists, optometrists, hospitals, nursing homes, health insurance premiums, cost of prescription medicine, eyeglasses, and so forth.

Check one box:
__ No
__ Yes

TYPE OF MEDICAL EXPENSE ___________

Amount This Family Paid

Dollars $___ Cents ___

TYPE OF MEDICAL EXPENSE ___________

Amount This Family Paid

Dollars $___ Cents ___

TYPE OF MEDICAL EXPENSE ___________

Amount This Family Paid

Dollars $___ Cents ___

3. Please print the name of the person or persons who completed this form

Name ___________

Name ___________