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Do you have a mental health, substance abuse or other disabilities that limit your ability to work or perform activities <br />of daily living? ❑ Yes* ❑ No <br />................................................................................ ............................... <br />THANK and END SURVEY. ❑ CHECK BOX WHEN THIS SURVEY <br />7. OTHER ADULT INHO(f HAS BEEN ENTERED INTO HMIS <br />................................................................................ ............................... <br />First Name: <br />Last Name: <br />Date of Birth: l l OR if DOB refused, Age: <br />Gender: ❑ Male ❑ Female ❑ Transgender ❑ Unknown /Refused <br />Have you served in the U.S. Armed Forces? ❑ Yes ❑ No ❑ Unknown ❑ Refused <br />Were you activated, into active duty, as a National Guard member or Reservist? <br />❑ Yes ❑ No ❑ Unknown ❑ Refused <br />Do you have a mental health, substance abuse or other disabilities that limit your ability to work or perform activities <br />of daily living? ❑ Yes* ❑ No <br />(if there are more adults in the Household attach another Household Survey to this Survey) <br />Outreach Workers Only: Check Box if information was filled out by you because client refused to fill out the survey due to <br />Severe Mental Illness and or Substance Abuse in addition please provide, please provide specific location where the <br />person was found AND identifying descriptors — hair color and length, body build, tattoos, scars, wounds, disabilities, etc.) <br />❑ Check if survey was filled out by Outreach Worker <br />Description: <br />17 <br />