Please indicate your sex:

What is your age?

What was the highest level of education that you have completed?

Has a doctor and/or another health care professional told you that you have one or more of the following diseases or chronic health conditions?

Check all that apply.

Has a doctor and/or another health care professional told you that you have less than 6 months to live?

Have you had any difficulty with the following tasks in the past week?

How much difficulty did you have with those tasks in the past week?

Have you had any difficulty with the following tasks in the past 3 days?

How much assistance did you need or have maintaining your personal hygiene in the past 3 days?

How much assistance did you need or have using the bathroom/toilet in the past 3 days?

How much assistance did you need or have getting around in the past 3 days?

How much assistance did you need or have eating in the past 3 days?

Has your ability to carry out these tasks gotten worse over the past 3 months?

Has your ability to make decisions worsened over the last 90 days?

e.g., when to get up or have meals, which clothes to wear, or what activities to do

Have you experienced any of the following symptoms or conditions in the last 3 days?

Have you been prescribed or are you currently receiving any of the following treatment(s)?

Check all that apply

Have you been scheduled for or begun treatment?

In the past 3 months, how many times were you hospitalized?

i.e., admitted and stayed in a hospital overnight

In the past 3 months, how many times did you seek care in an emergency department?