____ City (or county)
b. How many of these -- nights were during the past 2 weeks?
c. Was -- still in the hospital (nursing home) last Sunday night for this hospitalization (stay)?
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? If "No" ask: What was the matter?
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 at birth
 Acc. or inj
____Part of body
0 N (Next Hosp)
b. What was the name of the operation?
c. Any other operations during this stay?
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.