CSCTC Confidential Treatment Application

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Give us a brief description of your problem, injury, or disease
Tick the box next to the response that best fits your situation
1. Do you need any help looking after yourself?
I need no help at allOccasionally I need some help with personal care tasksI need help with the more difficult personal care tasksI need daily help with most or all personal care tasks
2. When doing household tasks: (For example: preparing food, gardening, using the video recorder, radio, telephone or washing the car.)
I need no help at allOccasionally I need some help with household tasksI need help with the more difficult household tasksI need daily help with most or all household tasks
3. Thinking about how easily you can get around your home and community:
I get around my home and community by myself without any difficultyI find it difficult to get around my home and community by myselfI cannot get around the community by myself, but I can get around my home with some difficultyI cannot get around either the community or my home by myself
4. Because of your health, your relationships (for example: with your friends, partner or parents)
generally:
Are very close and warmAre sometimes close and warmAre seldom close and warmI have no close and warm relationships
5. Thinking about your relationship with other people:
I have plenty of friends, and am never lonelyAlthough I have friends, I am occasionally lonelyI have some friends, but am often lonely for companyI am socially isolated and feel lonely
6. Thinking about your health and my relationship with my family:
My role in the family is unaffected by my healthThere are some parts of my family role I cannot carry outThere are many parts of my family role I cannot carry outI cannot carry out any part of my family role
7. Thinking about your vision, including when using your glasses or contact lenses if needed:
I see normallyI have some difficulty focusing on things, or I do not see them sharply For example: small print, a newspaper or seeing objects in the distance.I have a lot of difficulty seeing things My vision is blurred. For example: I can see just enough to get by with.I only see general shapes, or am blind For example: I need a guide to move around.
8. Thinking about your hearing, including using your hearing aid if needed:
I hear normallyI have some difficulty hearing or I do not hear clearly For example: I ask people to speak up, or turn up the TV or radio volume.I have difficulty hearing things clearly For example: Often I do not understand what is said. I usually do not take part in conversations because I cannot hear what is said.I hear very little indeed For example: I cannot fully understand loud voices speaking directly to me.
9. When you communicate with others: (For example: by talking, listening, writing or signing.)
I have no trouble speaking to them or understanding what they are sayingI have some difficulty being understood by people who do not know me. I have no trouble understanding what others are saying to me.I am only understood by people who know me well. I have great trouble understanding what others are saying to me.I cannot adequately communicate with others
10. Thinking about how you sleep:
I am able to sleep without difficulty most of the timeMy sleep is interrupted some of the time, but I am usually able to go back to sleep without difficultyMy sleep is interrupted most nights, but I am usually able to go back to sleep without difficultyI sleep in short bursts only. I am awake most of the nights
11. Thinking about how you generally feel:
I do not feel anxious, worried or depressedI am slightly anxious, worried or depressedI feel moderately anxious, worried or depressedI am extremely anxious, worried or depressed
12. How much pain or discomfort do you experience:
None at allI have moderate painI suffer from severe painI suffer unbearable pain
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Please note: If you do not hear back from the office within 72-hours, would you please contact us at our toll-free number: 847-367-8815.