[p. 155]
J. HOSPITAL PAGE
HOSPITAL STAY 1
2. You said earlier that -- was a patient in the hospital since (13-month hospital date) a year ago. On what date did [hw/she] 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?
*For delivery ask:
* For newborn ask:
* For initial "No condition" ask: Why did -- enter the hospital? ____
*For tests, ask: What were the results of the tests? ____
2 [] Normal at birth (5)
3 [] No condition (5)
[] Condition ____
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. ____
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 ____