Questionnaire Text

Questionnaire form view entire document:  text  image

30. Do you have, from birth or other cause, any physical or mental disability?
Mark one or more boxes, as appropriate

Blind

[] 1 From birth
[] 2 Other cause

Deaf-mute

[] 3 From birth
[] 4 Other cause

Mental retardation

[] 5 From birth
[] 6 Other cause

Paralysis or other physical disability

[] 7 From birth
[] 8 Other cause

[] 9 No disability

Questionnaire instructions view entire document:  text  image

For persons up to 40 years of age

Question 30 Do you have, from birth or other cause, any physical or mental disability?

Mark one or more boxes according to the following definitions.
a. Blind: The person has no vision or sees very little (visual weaknesses).
b. Deaf: The person does not see or talk, communicates through signs but with normal intelligence.
c. Mental retardation: consists of a below average or below normal intellectual capacity and is seen through growing up and the development of the person.
d. Invalid: is a person who through injuries in the locomotive system is not self-sufficient. It includes those who suffer from cerebral paralysis and those paralyzed in the arm or leg. Do not include those who walk with crutches or lack an arm.

If the person does not have any impediment, mark the corresponding box.