Attachment K-Resident Showcards2

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Attachment K

SHOWCARDS

Resident Questionnaire

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SHOWCARD 1

A4. PLEASE SELECT ALL THAT APPLY.

1. White/Caucasian

2. Black or African American

3. Asian

4. Native Hawaiian or other Pacific Islander

5. American Indian or Alaskan Native

6. Other (SPECIFY)____________________

SHOWCARD 2

B1a.

1. 0 to 3 months

2. More than 3 months to 6 months

3. More than 6 months to 1 year

4. More than 1 year to 3 years

5. More than 3 year to 5 years

6. More than 5 years

SHOWCARD 3

B3.

1. Private home/apartment/rented room/family residence

2. Different residential care/assisted living/group home facility

3. Retirement/independent living community

4. Nursing home (this excludes short nursing home stays for rehabilitation)

5. Other (specify):___________________

SHOWCARD 4

C1. PLEASE SELECT ALL THAT APPLY

a. Diabetes O

b. Partial or total paralysis O

c. Alzheimer’s disease or other dementia O

d. Arthritis or rheumatoid artritis O

Gout, lupus, or fibromyalgia O

e. High blood pressure or hypertension O

f. Congestive heart failure O

g. Coronary heart disease O

h. Heart attack (myocardial infraction)

i. Any other kind of heart condition or heart disease

(other than listed above) O

j. Stroke O

k. Kidney disease O

l. Cancer or malignant neoplasm of any kind

Bladder O

Blood O

Bone O

Brain O

Breast O

Cervix O

Colon O

Esophagus O

Gallbladder O

Kidney O

Larynx-windpipe O

Leukemia O

Liver O

Lung O Lymphoma O

Melanoma O

Mouth/tongue/lip O

Ovary O

Pancreas O

Prostate O

Rectum O

Skin (non-melanoma) O

Skin (DK what kind) O

Soft tissue (muscle or fat) O

Stomach O

Testis O

Throat – pharynx O

Thyroid O

Uterus O

Other O

Refused O

Don’t know O

m. Asthma O

n. emphysema O

o. chronic bronchitis O

p. COPD O

q. Cerebral Palsy O

r. Muscular Dystrophy O

s. Osteoporosis O

t. Nervous system disorders, including multiple sclerosis,

Parkinson’s disease, and epilepsy O

u. Serious mental problems such as schizophrenia or psychosis. O

Depression

v. Other mental, emotional, nervous condition, or depression O

w. Intellectual or developmental disabilities such as mental retardation,

severe autism, or Down syndrome O

x. Spinal cord injury O

y. Traumatic brain injury O

z. Other: SPECIFY: ___________________ O

SHOWCARD X

C X

0 not at all difficult

1 only a little difficult

2 somewhat difficult

3 very difficult

4 can’t do at all

5 do not do this activity

6 refused

7 don’t know

SHOWCARD 5

C18.

1. RN

2. LPN

3. Certified medication aide or supervisor

4. Personal care aide

5. Activity director/staff

6. Owner, administrator, director, or manager

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