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What is your opinion of your health?
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How satisfied are you with you life?
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In the past 7 days, how much pain have you felt?
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Do you exercise 5x/wk?
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Do you eat 4 servings of fruit and veggies a day?
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Does your diet include whole grain and fiber?
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Do you avoid high fat foods?
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How would you describe the overall condition of your mouth including teeth and dentures?
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How much do you drink?
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Do you ever drink 5+ drinks at one time?
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Do you always fasten your seatbelt when you are in the car?
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Do you or any of your friends/family members have concern about your memory?
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Do you have trouble with your hearing?
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Do you know where to locate a first aid kit/fire extinguisher in case of an emergency?
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Last week, did you need help with getting dressed, bathing, using the toilet, or eating?
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Last week, did you need help from others for laundry, housekeeping, banking, shopping, using the phone, or prepping medications
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Last week did you have a problem staying or falling asleep?
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Have you been constipated in the last 7 days?
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In the past year, have you fallen?
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Grab bars in the bathroom
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Handrails on stairs?
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Does your home have good lighting?
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Do you drive your own car?
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Are you a smoker?
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Have you fallen more than twice this year?
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