1. Do you currently live and receive care in or use, have applied to, or have been advised to reside in a nursing home, assisted living facility, any other residential care facility, home health care or adult day care?
2. Do you currently need any assistance or supervision in performing any of the following activities of daily living: bathing, dressing, eating, walking, moving in or out of a bed or chair, toileting and/or bowel/bladder control?
3. Do you currently use a wheelchair, motorized scooter, stair lift, Hoyer lift or respirator?
4. Have you been diagnosed or advised by a member of the medical profession as having or been treated for any of the following conditions in the past five years: heart attack, bypass angioplasty, stent surgery of the heart or legs, COPD, chronic kidney failure, cancer of the bone/esophagus/liver/lung/ovary/pancreas/stomach/uterus, lymphoma, leukemia or any metastatic cancer?
5. In the past five years, have you received Social Security Disability Insurance benefits?