Questionnaire Text

Questionnaire form view entire document:  text  image

5. Do you/does the person have any permanent limitation in:


Bathing, dressing or eating without assistance

[] 1 Yes
[] 2 No

Questionnaire instructions view entire document:  text  image

Question 5: Do you/does this person have any permanent disability in
If a person has more than one permanent disability you may circle all of them; you do not need to limit yourself to a single response. Exclude temporary disabilities caused by fractured limbs or illness.