Questionnaire Text

Questionnaire form view entire document: text image

10. Does this person have a disability? (Check off as many boxes as apply)

[] 01 No disability
[] 02 Blind
[] 03 Deaf
[] 04 Mute
[] 05 Upper limbs
[] 06 Lower limbs
[] 07 Mentally retarded
[] 08 Mental illness [problème mental]
[] 09 Other