|
|
|
|
|
3) Number of family members live within house ......... |
| |
|
|
|
|
|
|
5) Do you have a physical condition that affects your ability to walk? |
| |
|
|
|
|
6) Do you have any relative or closed friends within neighborhood? |
| |
|
|
|
|
7) 1. Number of employees within house hold?....... |
| |
|
|
|
|
|
|
9)Number of stories in house...... |
| |
|
|
|
|
|