Questionnaire Text

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18. Does this person have a physical, mental, or other health condition that has lasted for 6 or more months and which --

18a. Limits the kind or amount of work this person can do at a job?

[] Yes
[] No

[Mark yes to part (a) if a health condition substantially limits this person in his or her choice of occupation or if the condition limits the amount of work that can be accomplished in a given period of time.]

18b. Prevents this person from working at a job?

[] Yes
[] No

[Mark yes to part (b) if the health condition prevents this person from holding any significant employment.]