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Signed in as:
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1. Have you seen a physician within 6 months?
Yes _____ No _____
____Arthritis Cancer
____Suffered a stroke
____Open wounds
____Forgetfulness
____Diabetes
____Alzheimer's
____Hip or knee or back pain for more than a month
____Parkinson's disease
____Don't know
____None of the above
HOSPITAL
____Yes
____No
____Don't know
REHABILITATION
____Yes
____No
____Don't know
NURSING HOME
____Yes
____No
____Don't know
Do you take prescribed medicine?
____ Yes
____ No
____Don't know
Nutritional Risk Screen:Do you have a special diet your doctor ordered?
____Yes
____No
____Don't know
Each day, do you take 3 or more prescription drugs or medications bought in the drug store without a prescription?
____Yes
____No
____Don't know
Are you unable to shop, cook, or feed yourself?
____Yes
____No
____Don't know
Walking on even or uneven surfaces:
____No problem
____Needs help of a device (walker, cane, or wheelchair
____Needs the help of a person
____Don't know
Going up the stairs:
____No problem
____Needs help of a device (walker, cane, or wheelchair
____Needs the help of a person
____Don't know
Tell us how safely you feel that you can use a wheelchair:
____No problem can wheel self
____Needs assistance to be mobile
____Don't know
____Doesn't require a wheelchair
Can you get up and out of a chair or bed, on and off the toilet, and in and out of the tub?
How well can you get up and out of a chair?
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
How well can you get up and out of bed?
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
How well can you get out on and off the toilet?
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
How well can you get in and out of the tub or the shower?
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
How well can you bathe?
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Tell us how well you can dress and groom each day:
Teeth or Denture Care
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Washing and combing hair
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Facial Care (Shaving or applying make up)
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Dressing self
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Walking and combing hair
____No problem
____Needs help using a device
____Needs the help of a person
____Don't know
Laundry
____No problem
____Needs assistance
____Don't know
Housekeeping
____No problem
____Needs assistance
____Don't know
Shopping
____No problem
____Needs assistance
____Don't know
Can you use the telephone and dial the numbers?
____No problem
____Needs assistance
____Don't know
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