Question Grid

Name

qg_6_c_i

Label

6 c(i)

Question Text

Please give the following details about each admission including any accidents or infectious diseases noted in Sections I or II.

Nature of illness Nature of operation performed (if any) Date of admission
Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text
1
2

Usage

43 questions before...

Has this child been an IN-PATIENT in a HOSPITAL or NURSING HOME since OCTOBER 1954.

1
Yes
0
No
Please give the following details about each admission including any accidents or infectious diseases noted in Sections I or II.
Nature of illness Nature of operation performed (if any) Date of admission
Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text Generic textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric text
1
2
Please give the following details about each admission including any accidents or infectious diseases noted in Sections I or II.
Name and Address of Hospital or Nursing Home Name of Doctor or Specialist in Charge of Child
Generic textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric text
1
2
46 questions after...
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Dimensions

Code Dimension

Type
Code List
Selection Style
SelectOne
Display Code
False
Display Label
True

Code Dimension

Type
Code List
Selection Style
SelectOne
Display Code
False
Display Label
False

Response Options

Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
1
Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
2
Type
Date/Time
Type
Date
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
3
Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
4
Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
5
Type
Date/Time
Type
Date
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
6
Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
7
Type
Date/Time
Type
Date
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
8
Type
Text
Maximum Length
255
Rank
1
All Values
True
Rank
2
All Values
False
Specific Value
9