1 - ESDS

.b
No of
SOxes/
Characters
Q5 Q5 2 Valu*s -3-0’4
Q5(A) MNTH 1 2
Codang Instructions/R9marks
v~slt as outpatmnt?
Yes .. ................. .01
NO ............... . ......02
values -- u
Q5(B) visits 2
Values -3-1o
Q5 (A) NNTH 2
Q5(B)
Q5(A) MNTH 3 2
Q5(B) Vialt, 2
2 Valuma -- 12
vis Lt9 2 yQJJ!es -- lQ
Enter number of month for
earliest v~sit
Entar numhar of vlsltn for
●arl last month
Enter number of month for
●mcond VLSLt
Enter nUmh_r of vLsit9 Ln
sacond month
ValUQS -3-12
Enter number of month for
third v~s~t
ValUaS -3-lQ
Q6 Q6
2 Values -3-02
Enter number of Visits Ln
thLrd month
Inpat~ent during last yearz
Yes .. . ....... ....... .01
NO ... .......... ... 02
131