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Reset Questionnaire
Complete the questions below as they apply to you.
1. Do you have an illness that causes pain or trouble breathing?
Yes
No
2. Have you had a change in your ability to perform daily activities such as walking, eating, bathing, dressing, or going to the bathroom?
Yes
No
3. Do you have a hard time keeping your balance while standing or walking?
Yes
No
4. Have you fallen recently and had a hard time getting up?
Yes
No
5. Have you been admitted to the hospital or had to go to the emergency room more than once in the past 6 months?
Yes
No
6. Have you had frequent infections such as urinary tract infections or pneumonia in the past 6 months?
Yes
No
7. Do you have an illness that you are getting treatment for but it is no longer working?
Yes
No
8. Do the side effects of treatment outweigh the benefits?
Yes
No
9. Would you rather be cared for by professionals in the comfort of your own home instead of doctors' offices and hospitals?
Yes
No
10. Do you think your family members would benefit from additional help and support?
Yes
No
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