2-WEEKS DOCTOR VISIT PAGE
7777 Last week
8888 Week before
b. Were there any other doctor visits for him during that period?
N (Ask 3-6 for each visit)
3. Where did he see the doctor on the (date) at a clinic, hospital, doctor's office, or some other place?
If hospital: Was it the outpatient clinic or the emergency room?
If Clinic: Was it a hospital outpatient clinic, or some other kind of clinic?
1 Doctor's office (group practice or doctor's clinic)
3 Hospital Outpatient Clinic
5 Hospital Emergency Room
6 Company or Industry Clinic
1 Diag. or treatment (6c)
3 General checkup (6b)
2 Pre or Postnatal care (Next DV)
4 Eye exam. (glasses) } (Next DV)
5 Immunization (Next DV)
6 Other ____
b. Was this for any specific condition?
N (Next DV)
Mark box or ask:
c. For what condition did -- visit (call) the doctor on (date)?
A condition page is required for the condition in question 6. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required doctor visits.