Does the applicant have Medicaid/MO Healthnet insurance?
What medical condition has the applicant been diagnosed with? (Please select all that apply)
Do you have any the following conditions? (Select all that apply)
Do you have any of the following equipment? (Select all that apply)
Do you take prescribed medications?
Do you have medical treatments, either at home or away, such as dialysis, or chemotherapy, or the use of catheters or ostomy bags, or the like?
Do you receive rehab services such as PT, OT, or ST?
Do you need aide in personal care, such as dressing, grooming, toileting program or use of toileting aides?
Are you able to prepare meals for yourself? Do you have a special diet (i.e. diabetic or renal diet) or need feeding?
Do you have any memory problems/loss, have difficultly remembering to take meds or paying bills? Can you self-direct your own medical and personal care?
Do you have mobility issues that requires someone to help you get around, turning/positioning you in bed, or help you in/out of bed or chairs?
