Question Grid

Name

qg_6_c_ii

Label

6 c(ii)

Question Text

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

Usage

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

(When a single illness involves more than one admission give information separately for each period in hospital)

Nature of illness Nature of operation performed (if any) Date of Admission
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
Please give the following details about each admission including any accidents or infectious diseases noted in Sections I or II.

(When a single illness involves more than one admission give information separately for each period in hospital)

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
(Include child guidance and all other clinics wherever held)
64 questions after...
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Dimensions

Code Dimension

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

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
Text
Maximum Length
255
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