Questionnaire Text

Questionnaire form view entire document: text image

H. Answer question 19a-c if this person is 5 years old or over. Otherwise, skip to the questions for Person 2 on page 19.

19c. Does this person have difficulty dressing or bathing?

[] Yes
[] No

Questionnaire instructions view entire document: text image

Person questions 19

Answer question 19a-c if this person is 5 years old or over. Otherwise skip to the questions for Person 2 on page 19.

P19. 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.