[p. 78]
HOSPITAL PAGE
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
Date ____
Year 19 _ _
3. What is the name and address of this hospital (nursing home)?
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)?
[] 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 newborn, ask: Was the baby normal at birth?
Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.
[] Normal at birth
Condition ____
Cause ____
[] Acc. or Inj.
Part of body ____
7a. Were any operations performed on -- during this stay in the hospital (nursing home)?
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?
[] N
If newborn go to next hosp; otherwise ask:
8. At the time -- entered the hospital was he living at this address?
2 [] N
9. In what city (town), county, and State was -- living?
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?)
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.]
Date ____
Year 19 _ _
Street ____
City (or county) ____
State ____
b. Nights ____
c.
[] N
[] Normal at birth
Condition ____
Cause ____
[] Acc. or Inj.
Part of body ____
0 [] N (8)
b. ____
c.
[] N
2 [] N
County ____
State ____
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.