O
O
O
O
a. Paying for food
b. Skipping meals due to lack of money
O
O
O
O
O
O
O
O
c. Making food for yourself
6. Do you have any pets such as dogs, cats, or birds?
7. Do you ever go without food so you can feed your pet(s)?
O Yes
O Yes
O No
O No O NA, I don’t have pets
8. For each of the following, please mark the response that best describes how often it is an issue for you. Never Rarely Sometimes Often a. Bathing and other personal hygiene O O O O
O
O
O
O
b. Getting dressed
c. Need for mobility aids (e.g., wheelchair, walker, etc.)
O
O
O
O
O
O
O
O
d. Falling or almost falling
e. Limiting activities due to a fear of falling
O
O
O
O
O
O
O
O
f. Hearing
O
O
O
O
g. Vision
9. For each of the following, please mark the response that best describes how often it is an issue for you. Never Rarely Sometimes Often a. Moving from one place to another inside your home O O O O
O
O
O
O
b. Walking one block
Region II: PCOA
Area Plan 2024-2027
Page 70 of 113
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