Have you spent the night in a hospital since <date 90 days prior to enrollment call>?

Y

Yes

N

No

U

Unknown

R

Refused

Have you used the emergency room more than once within <date 90 days prior to enrollment call>?

Y

Yes

N

No

U

Unknown

R

Refused

Do you currently receive Physical or Occupational Therapy?

Y

Yes

N

No

U

Unknown

R

Refused

Do you use oxygen at home?

Y

Yes

N

No

U

Unknown

R

Refused

Do you currently receive Dialysis?

Y

Yes

N

No

U

Unknown

R

Refused

Does a nurse, therapist or nurse aide visit you in your home?

Y

Yes

N

No

U

Unknown

R

Refused

Are you currently living in a nursing home?

Y

Yes

N

No

U

Unknown

R

Refused

Do you need help with any personal services such as bathing, dressing or assistance making meals?

Y

Yes

N

No

U

Unknown

R

Refused

Have you had health problems because you cannot get the services you need?

Y

Yes

N

No

U

Unknown

R

Refused