Official websites use .gov
A
.gov website belongs to an official
government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you've safely
connected to the .gov website. Share sensitive
information only on official, secure websites.
Items in the short questionnaire on self reported ability to care for self and others and accidental injuries
| Item | Yes | No | |
| 1 | In the past 3 months have you had any accidents? | ||
| Specify type of accident | |||
| 2 | In the past 3 months have you had any treatment for an accidental injury? | ||
| Specify treatment | |||
| 3 | Does your eyesight prevent you from attending to the needs of a spouse, relative or friend? | ||
| 4 | Does your eyesight prevent you from attending to your own needs? |
