Questionnaire Text

Questionnaire form view entire document:  text  image
[G] - Answer question 18a-c if this person is 5 years old or over. Otherwise, skip to the questions for person 2 on page 12.

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.