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Have you or a loved one...
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Have you or a loved one...
Yes
No
1) Been hospitalized or gone to ER several times in past 6 months?
Have you or a loved one...: 1) Been hospitalized or gone to ER several times in past 6 months? (Yes)
1) Been hospitalized or gone to ER several times in past 6 months? (No)
2) Been making more frequent phone calls to your physicians?
2) Been making more frequent phone calls to your physicians? (Yes)
2) Been making more frequent phone calls to your physicians? (No)
3) Started taking medication to lessen physical pain?
3) Started taking medication to lessen physical pain? (Yes)
3) Started taking medication to lessen physical pain? (No)
4) Started spending most of the day in a chair or bed?
4) Started spending most of the day in a chair or bed? (Yes)
4) Started spending most of the day in a chair or bed? (No)
5) Fallen several times over the past 6 months?
5) Fallen several times over the past 6 months? (Yes)
5) Fallen several times over the past 6 months? (No)
6) Started needing help with one or more of the following? (bathing, dressing, eating, getting out of bed, walking)
6) Started needing help with one or more of the following? (bathing, dressing, eating, getting out of bed, walking) (Yes)
6) Started needing help with one or more of the following? (bathing, dressing, eating, getting out of bed, walking) (No)
7) Started feeling weaker or more tired?
7) Started feeling weaker or more tired? (Yes)
7) Started feeling weaker or more tired? (No)
8) Experienced weight loss making clothes noticeably looser?
8) Experienced weight loss making clothes noticeably looser? (Yes)
8) Experienced weight loss making clothes noticeably looser? (No)
9) Noticed a shortness of breath, even while resting?
9) Noticed a shortness of breath, even while resting? (Yes)
9) Noticed a shortness of breath, even while resting? (No)
10) Been told by a doctor that life expectancy is limited?
10) Been told by a doctor that life expectancy is limited? (Yes)
10) Been told by a doctor that life expectancy is limited? (No)
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