Questionnaire Text

Questionnaire form view entire document: text image

5. Is your mother alive?

[] 1 Yes
[] 2 No
[] 3 Doesn't know

Questionnaire instructions view entire document: text image

I. For all persons. General characteristics

Question 5. Is your mother alive?

Make an X in the corresponding box.

[A depiction of question 5 to the right of the preceding text is omitted here.]