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* 1. Today's Date

Date

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

Date

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* 5. Email

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* 6. SMS Text

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* 7. What medications you are currently taking, including how often and the dose:

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* 8. Have you had trouble filling medications in the last year?

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* 9. Thinking over the past week, were there any days you did not take your medications as prescribed?

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* 10. Would you like assistance with taking your medication as prescribed?

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* 11. During the past week, how much did pain interfere with your normal activities (including work outside the home and/or housework)?

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* 12. Do you need help with any of these actions? (Check all that apply)

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* 13. Are you getting all the help you need with these actions?

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* 14. Have you fallen the last month?

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* 15. Are you afraid of falling?

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* 16. Do friends or family members express concerns about your ability to care for yourself?

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* 17. Do you use or need any of the following? (Select all that apply.):

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* 18. In general, how would you describe your physical health?

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* 19. Please provide additional information about why you chose this rating.

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* 20. Compared to one year ago, how would you describe your physical health?

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* 21. Please provide additional information about why you chose this rating.

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* 22. How many times have you been to the emergency room in the past six months?

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* 23. How many times have you been a patient in the hospital in the past six months?

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* 24. How many times have you been a patient in the hospital in the past six months?

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* 25. In the last 12 months, how many times have you been in a nursing home and/or rehab?

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* 26. Do you have a regular or specialty doctor or healthcare provider?

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* 27. Who is the Provider (name/clinic/phone)?

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* 28. When was the last time you saw your regular doctor?

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* 29. Are you currently pregnant or the father of a pregnant woman?

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* 30. Have you given birth in the last 12 months?

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* 31. When was your last dental visit?

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* 32. Do you have any problems eating (for example, appetite, chewing or swallowing)?

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* 33. Have you been told by a doctor that you have any medical conditions?

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* 34. Do you have any other conditions not listed above?

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* 35. Do you have trouble with your vision?

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* 36. If you have diabetes, have you had a diabetic eye exam done in the last year?

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* 37. Do you have trouble with your hearing?

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* 38. Are you getting wound care from a healthcare professional or care team now?

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* 39. Have you had any of the following vaccinations as an adult?

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* 40. Have you had the following screenings/tests?

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