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 -- enter the hospital ([the last time/the time before that])?
Record each entry date in a separate Hospital Stay column.
Year 19_ _
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 ____
 No nights in 2-week reference period (5)
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?
Number and street ____
City or County State ____