Updated research request forms and data security approval requirement effective 4/24/23
Structural barriers: stairs inside which must be used by patient.
Structural barriers: stairs inside home which are used optionally.
Structural barriers: stairs leading from inside to outside house.
Safety hazards: improperly stored hazardous materials.
Safety hazards: inadequate cooling.
Safety hazards: inadequate floor, roof, or windows.
Safety hazards: inadequate heating.
Safety hazards: inadequate lighting.
Safety hazards: inadequate stair railings.
Safety hazards: lack of fire safety devices.
Safety hazards: lead-based paint.
Safety hazards: none.
Safety hazards: other (specify).
Safety hazards: unsafe floor coverings.
Safety hazards: unsafe gas/electric appliance.
Sanitation hazards: cluttered/soiled living area.
Sanitation hazards: contaminated water.
Sanitation hazards: inadequate sewage disposal.
Sanitation hazards: inadequate/improper food storage.
Sanitation hazards: insects/rodents present.
Sanitation hazards: no cooking facilities.
Sanitation hazards: no food refrigeration.
Sanitation hazards: no running water.
Sanitation hazards: none.
Sanitation hazards: no scheduled trash pickup.
Sanitation hazards: no toileting facilities.
Sanitation hazards: other (specify).
Sanitation hazards: outdoor toileting facilities only.
Patient lives alone.
Patient lives with friend.
Patient lives with other family member.
Patient lives with other than above.
Patient lives with paid help.
Patient lives with spouse or significant other.
Assisting person(s): none of the above.
Assisting person(s): paid help.
Assisting person(s): person residing in the home (excluding paid help).
Assisting person(s): relatives, friends, or neighbors living outside the home.
Assisting person(s): unknown.
Primary caregiver taking lead responsibility.
How often does patient receive assistance from primary caregiver.
Type of primary caregiver assistance: ADL assistance.
Type of primary caregiver assistance: advocates or facilitates patient's participation in appropriate medical care.
Type of primary caregiver assistance: environmental support.
Type of primary caregiver assistance: financial agent, power of attorney, or conservator of finance.
Type of primary caregiver assistance: health care agent, conservator of person, medical power of attorney.
Type of primary caregiver assistance: IADL assistance.
Type of primary caregiver assistance: psychosocial support.
Type of primary caregiver assistance: unknown.
Vision with corrective lenses if the patient usually wears them.