Questionnaire Text

Questionnaire form view entire document: text image

[Question 18 was asked of persons age 5 and above.]

18. a) Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

[] Yes
[] No

Questionnaire instructions view entire document: text image

Answer person questions 18a through 18c if this person is 5 years old or over.

18a-18c. Mark the "Yes" or "No" box to indicate if the person has serious difficulty with any of the activities listed in parts a, b, and c because of a physical, mental, or emotional condition.