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hosp
[p. 70]

Hospital Page

1. Person number ____

You said that -- was in the hospital (nursing home) during the past year.
Use your calendar -- Make sure the year is correct.

2. When did -- enter the hospital (nursing home) (the last time)?

____ Month
____ Date
____ Year

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 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.
Show cause, kind and part of body in same detail as required for the Condition page
For delivery ask:
Was this a normal delivery?
If "No," ask: What was the matter?
For newborn, ask:
Was the baby normal at birth?
If "No," ask: What was the matter?

[] 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 at the hospital (nursing home)?

[] Y
[] 0 N (Next Hosp)

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

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 in condition in item C and fill a page for it after completing columns for all required hospitalizations.