Questionnaire Text

Questionnaire form view entire document:  text  image
16. Because of a physical, mental, or emotional condition lasting 6 months or more, does this person have any difficulty in doing any of the following activities:

a) Learning, remembering, or concentrating?

[ ] Yes [ ] No

Questionnaire instructions view entire document:  text  image
16.Mark the "Yes" or "No" box for parts a and b of question 16 to indicate whether the person has any difficulty doing any of the activities listed.