Pace New Enrollment Application Form - Pennsylvania Department Of Aging Page 4
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612.
Are you LIMITED in any way in any activities because of any impairment or health problem?
1. Yes
2. No. If No, Go to Question 17.
13.
What is the MAJOR impairment or health problem that limits your activities?
14. For HOW LONG have your activities been limited because of your major impairment or
health problem? Please give the length of time.
15.
Because of any impairment or health problem, do you need the help of other persons with
your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house?
Yes
No
1.
2.
16.
Because of any impairment or health problem, do you need the help of other persons in
handling your ROUTINE needs, such as everyday household chores, doing necessary
business, shopping, or getting around for other purposes?
Yes
No
1.
2.
Your answers to the following questions will help PACE/PACENET understand how people
receive and use their prescription medications.
17.
Because of vision problems, or any other problem, how often do you have difficulty in
reading and understanding the instructions that are on medicine labels, or that are given
to you in writing by your physician or pharmacist?
Never
Rarely
Sometimes
Often
Very Often
.
1.
2
3.
4.
5.
18.
Is there a friend or family member that helps you read and understand labels on medicine
containers, and the instructions from the physician or pharmacist?
Sometimes
Yes
No
3.
1.
2.
19.
People report that they forget to take their medicines, for instance they forget to take the
correct amount, or at the correct time. How often do you forget to take any of your medicines?
Never
Rarely
Sometimes
Often
Very Often
.
1.
2
3.
4.
5.
20. Sometimes people report that they intentionally take LESS medicine than prescribed, for
various reasons. For example, they may decide to take fewer tablets or take the medicine
less often. Do you ever intentionally take LESS medicine than was prescribed?
Never
Rarely
Sometimes
Often
Very Often
.
1.
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3.
4.
5.
21. Sometimes people report that they intentionally take MORE medicine than prescribed, for
various reasons. For example, they may decide to take extra tablets or take the medicine
more often. Do you ever intentionally take MORE medicine than was prescribed?
Never
Rarely
Sometimes
Often
Very Often
.
1.
2
3.
4.
5.
THANK YOU. YOUR ANSWERS WILL HELP US TO IMPROVE THE DELIVERY
OF HEALTH CARE SERVICES AND BENEFITS FOR OLDER PENNSYLVANIANS.
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