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Are you blind, or do you have serious difficulty seeing, even when wearing glasses?
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Are you deaf, or do you have serious difficulty hearing?
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Do you have serious difficulty walking or climbing stairs?
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Do you have difficulty dressing or bathing?
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Do you have difficulty remembering or concentrating?
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Using your usual language, do you have difficulty communicating (for example, understanding or being understood)?
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Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a physician's office or shopping
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Do you have difficulty reading or writing?
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Due to a disability, do you need any additional assistance or accommodations during your visit
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