[pg.161]
J. HOSPITAL PAGE
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.
Date ____
Year 19__
3. How many nights was -- in the hospital?
Nights ____
4. For what condition did -- enter the hospital?
2[] Normal at birth (5)
3[] No condition (5)
[] Condition ____
If "No" ask:
What was the matter?
*For newborn ask:
If "No" ask:
What was the matter?
*For initial "No condition" ask:
*For tests, ask:
If no results, ask:
Why were the tests performed?
J1
Refer to questions 2, 3, and 2-week reference period.
[] 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?
2[] No (6)
b. What was the name of the surgery or operation?
If name of operation not known, describe what was done.
2 ________
3 ________
c. Was there any other surgery or operation during this stay?
[] No
6. What is the name and address of this hospital?
Number and street ________
City or county ____
State ____