Questionnaire Text

Questionnaire form view entire document:  text  image
Section C: General health and Functioning
Ask of everyone listed in the flap.

P-12 Health and functioning
Does [the person have difficulty in the following?
Write the appropriate code [number from 1 to 6] in the box.

_ A. Seeing even when using eye glasses
_ B. Hearing even when using a hearing aid
_ C. Communicating in his/her language (i.e. understanding others or being understood by others)
_ D. Walking or climbing stairs
_ E. Remembering or concentrating
_ F. With self-care such as washing all over, dressing, or feeding
1. No difficulty
2. Some difficulty
3. A lot of difficulty
4. Cannot do at all
5. Do not know
6. Cannot yet be determined
Questionnaire instructions view entire document:  text  image
5. Section C: General health and functioning (remember to follow instructions)
Purpose: Helps to determine the number of people with disabilities in the country for planning and provision of services.

This section must be completed for every person listed on the questionnaire.