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_. _. Autre, Quel est votre statut professionnel actuel ? [_] Actif Dans ce cas, quelle profession exercez-vous ? Retraité Dans ce cas, A quel âge avez-vous pris votre retraite ?

. Si-oui, _. _. Pour-quelle, and . Actuellement, s) pathologie(s) ?, avez-vous la CMU (couverture maladie universelle) ? OUI [_] NON

_. _. Poids-en-kg, Une prestation relative à une invalidité ou à un handicap (AAH, Pension d'invalidité, minimum invalidité, AES) [_] Rentes accident du travail et maladie professionnelle [_] Minimum vieillesse [_] Prestation dépendance (APA, PSD) [_] Aides financières au logement [_] Autres (dont allocation veuvage, congés maladie longue durée) Précisez :Quel est le montant total mensuel des prestations dont vous bénéficiez ?, Quelles sont la ou les prestations que vous percevez actuellement avez vous une ou des pathologies (ex : HTA, Diabète, insuffisance cardiaque, dépression?) ? Oui [_] Non

. _. De-quoi, Consommations de toxiques Parmi les substances ci-dessous, avez-vous déjà utilisé l'une d'entre elles ?

S. :. Vous-commencé-À-fumer, Combien de cigarettes par jour actuellement, ) : Oui [_] Non

. Consommation-de-médicaments, Au cours de cette semaine (7 jours précédents), avez-vous consommé des médicaments ? Ne pas oublier les pilules, autres contraceptifs, somnifères, antalgiques, injections, vaccins, patch, crèmes, pommades etc

S. Oui, Donnez le nom précis de ces médicaments, leur dosage, le problème de santé pour lequel vous avez pris ce médicament, s'il a été prescrit ou s'il s'agit d'automédication, la quantité consommée ? Au cours des 12 derniers mois avez-vous bénéficié d'une prise en charge paramédicale à domicile ? OUI

S. Oui, Kinésithérapeute Nombre de prises en charge : _ _ _ _ _ _ _ par semaine

_. _. Ambulance, Donner les points de départ et d'arrivée ou donner le nombre approximatif de kilomètres des transports (un aller-retour=2 transports)