| 69857-1 | Are you blind, or do you have serious difficulty seeing, even when wearing glasses:Find:Pt:^Patient:Ord: | required |
| 69856-3 | Are you deaf, or do you have serious difficulty hearing:Find:Pt:^Patient:Ord: | required |
| 69859-7 | Do you have serious difficulty walking or climbing stairs:Find:Pt:^Patient:Ord: | required |
| 69860-5 | Do you have difficulty dressing or bathing:Find:Pt:^Patient:Ord: | required |
| 69858-9 | Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions:Find:Pt:^Patient:Ord: | required |
| 98068-0 | Difficulty communicating in usual language:Find:Pt:^Patient:Ord: | required |
| 69861-3 | Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a physician's office or shopping:Find:Pt:^Patient:Ord: | optional |
| 98078-9 | Difficulty reading or writing:Find:Pt:^Patient:Ord: | optional |
| 98079-7 | Do you need any additional assistance or accommodations during your visit:Find:Pt:^Patient:Ord: | optional |
| 98067-2 | Patient-centered disability questionnaire:-:Pt:^Patient:-: | |