[p.154]
J. Hospital Page
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?
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 test ask:
What were the results of the tests?
If no results, ask:
Why were the tests performed?
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.
(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 ____