[p. 157]
J. HOSPITAL PAGE
1. Refer to C1, "HOSP." box.
Hospital Stay 1
1. 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.
Date ____
Year 19 _ _
3. How many nights was -- in the hospital?
Nights ____
4. For what condition did -- enter the hospital?
* For delivery ask:
If "No," ask: If "No," ask:
* For newborn ask:
If "No," ask:
*For initial "No Condition," ask:
*For tests ask:
If no results, ask:
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 ____