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hosp

[p. 78]

HOSPITAL PAGE

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)?

USE YOUR CALENDAR
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)? ____

Complete 5 from entries in questions 2 and 4; if not clear, ask the questions.

5a. How many of these [response to question 4] nights were during the past 12 months? ____

b. How many of these [response to question 4] nights were during the past 2 weeks? ____

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 (8)

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 newborn go to next hosp; otherwise ask:
8. At the time -- entered the hospital was he living at this address?

1 [] Y (10)
2 [] N

9. In what city (town), county, and State was -- living?

City ____
County ____
State ____

10. About how long did it take -- to get to the hospital on (date in 2)?
(Was it less than 30 minutes or more than 30 minutes?)
(Was it less than one hour or more than one hour?)

1 [] Less than 30 minutes
2 [] 30-59 minutes
3 [] 60-89 minutes
4 [] 90+ minutes

P2
A Condition page is required if there is an entry of "1" or more nights in 5b. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required hospitalizations.

[p. 79]


[MK Note: Page 79 contains a response sheet for questions asked on page 78. The response sheet contains three columns in which to enter responses; only one is represented here since each column contains identical information.]

1. Person number ____

2.

Month ____
Date ____
Year 19 _ _

3.

Name ____
Street ____
City (or county) ____
State ____

4. Nights ____

5a. Nights ____

b. Nights ____

c.

[] Y
[] N

6.

[] Normal delivery
[] Normal at birth
Condition ____
Cause ____
[] On Card C
[] Acc. or Inj.
Kind ____
Part of body ____

7a.

[] Y
0 [] N (8)

b. ____

c.

[] Y (Describe) ____
[] N

8.

1 [] Y (10)
2 [] N

9.

City ____
County ____
State ____

10.

1 [] Less than 30 minutes
2 [] 30-59 minutes
3 [] 60-89 minutes
4 [] 90+ minutes


[MK Note: End response sheet.]

P2
A Condition page is required if there is an entry of "1" or more nights in 5b. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required hospitalizations.