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Form 1

Do you have difficulty seeing, even if wearing glasses?No – no difficultyYes – some difficultyYes – a lot of difficultyCannot do at all

Do you use a Vision Aid?

YesNo

Do you have difficulty hearing, even if using a hearing aid?

Do you have difficulty walking or climbing steps?No – no difficultyYes – some difficultyYes – a lot of difficultyCannot do at all

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