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1. Refer to C1, "HOSP." box.

Person number ____

2. You said earlier that -- was a patient in the hospital since (13-month hospital date) a year ago. On what date did -- enter the hospital ([the last time/the time before that])?
Record each entry date in a separate Hospital Stay column.

Month ____
Date ____
Year 19__

3. How many nights was -- in the hospital?

0000[] None (Next HS)
Nights ____

4. For what condition did -- enter the hospital?

1[] Normal delivery (5)
2[] Normal at birth (5)
3[] No condition (5)
[] Condition ____
*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?

*For initial "No condition" ask:
Why did -- enter the hospital?

*For tests, ask:
What were the results of the tests?
If no results, ask:
Why were the tests performed?

Refer to questions 2, 3, and 2-week reference period.

[] At least one night in 2-week reference period (Enter condition in C2, then 5)
[] No nights in 2 week reference period (5)

5a. Did -- have any kind of surgery or operation during this stay in the hospital, including bone settings and stitches?

1[] Yes
2[] No (6)

b. What was the name of the surgery or operation?
If name of operation not known, describe what was done.

1 ________
2 ________
3 ________

c. Was there any other surgery or operation during this stay?

[] Yes (Reask 5b and c)
[] No

6. What is the name and address of this hospital?

Name ____
Number and street ________
City or county ____
State ____