Data Cart

Your data extract

0 variables
0 samples
View Cart


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
19__ 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.
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 delivery
[] Normal at birth
____ Condition

[] 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

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.