PCA Services: Please tell us about your most recent PCA evaluation

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* 1. Name

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* 2. Where do you live?

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* 3. Email

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* 4. Phone

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* 5. Age of person using PCA services

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* 6. When was your most recent PCA evaluation?

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* 7. I received an increase in hours/minutes after the evaluation

Yes

No

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* 8. Number of hours/minutes increased

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* 9. I received a decrease in hours/minutes after the evaluation

Yes

No

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* 10. Number of hours/minutes decreased

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* 11. Please check the task that was decreased. Please check all that apply

Bathing

Bladder care

Bowel care

Dressing

Undressing

Eating

Assistance with Medications

Range of Motion ( ROM)

Mobility/Transfers

Shopping

Housekeeping

Laundry

Meal Prep

I do not know which task was cut

Other

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* 12. Please let us know what types of other problems you are having with PCA services

Thank you for for completing this survey!