Questionnaire Text

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F. Answer questions 15 and 16 only if this person is 5 years old or over. Otherwise, skip to the questions for Person 2 on page 10.


15a. Does this person have any of the following long-lasting conditions:


15b. A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting or carrying?

[] Yes
[] No

Questionnaire instructions view entire document:  text  image

[Housing Question 15 and 16 should only be asked of individuals 5 years and older]


15.
Mark the "Yes" or "No" box for both parts 15a. and 15b. of question 15 to indicate whether the person has any of the conditions listed.