Are you bedridden or confined to a wheelchair?
NoYes

Have you experienced the loss of two or more of any of the “activities of daily living”? (bathing, continence, dressing, eating, transferring, toileting)
NoYes

Do you suffer from diabetes with insulin, or emphysema, or asthma, or COPD?
NoYes

Are you scheduled to have surgery not yet completed, or have you been an in-patient in the hospital during the past 60 days?
NoYes

Within the past 2 years, have you been treated for cancer, or ALS, or Parkinsons, or cirrhosis, or stroke, or heart attack?
NoYes

Your name

Your email

Your phone number