Question Grid

Name

qg_5_c_i

Label

5 c(i)

Question Text

Please give the following details about each admission :

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

30 questions before...

Has this child been an IN-PATIENT in a HOSPITAL or NURSING HOME since JANUARY 1957 when he was ten years and nine months old?

1
Yes
0
No
X
No answer
Please give the following details about each admission :
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:
Name and Address of Hospital or Nursing Home Length of stay in Hospital or Nursing Home Name of Doctor or Specialist in charge of Child
Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text Generic textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric text
1
2
101 questions after...
View the complete questionnaire

Dimensions

Code Dimension

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

Code Dimension

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