Questionnaire Text

Questionnaire form view entire document:  text  image
c) Does this person have difficulty dressing or bathing?
[ ] Yes
[ ] No
[H] - Answer question 18 if this person is 15 years old or over. Otherwise, SKIP to the questions for Person 2 on page 12.
Questionnaire instructions view entire document:  text  image
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.