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Take the PACE
®
Eligibility Quiz
ELIGIBLE
*Required Information
1. Are you or your loved one 55 years of age or older (or will be in the next 3 months)?
*
Yes
No
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1a
2. Do you or your loved one have difficulty with any of the following tasks and would benefit from assistance? Check all that apply:
*
Managing finances or making big decisions
Scheduling medical appointments
Tracking medications
Self-care and hygiene including dressing and grooming
Bathroom needs (bathing, toilet, getting up or down)
Standing up from a seated position
Getting in and out of bed and/or in and out of vehicles
Expressing oneself and/or struggling with word-finding to communicate needs
Not applicable
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2a
Hidden
2b
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Please do not specify additional checkmarks when choosing "not applicable."
3. Do you or your loved one use any of the following treatments or have any of the following conditions? Check all that apply:
*
Supplemental oxygen
Dialysis in home or at a center
Intravenous or parenteral feedings
Physical therapy, short- or long-term
Other
Not applicable
If "Other," please specify:
Hidden
3a
Hidden
3b
Hidden
3result
Please do not specify additional checkmarks when choosing "not applicable."
4. Do you or your loved one have Medicaid?
*
Yes
No
Unsure
5. What is the permanent zip code of you or your loved one?
*
ZIP Code
Hidden
Final Tally
Email
This field is for validation purposes and should be left unchanged.
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