Are you currently hospitalized, confined to a nursing facility, a bed, or a wheelchair due to chronic illness or disease, currently using oxygen equipment to assist in breathing, receiving Hospice Care or home health care, or had an amputation caused by disease, or do you currently have any
form of cancer (excluding basal cell skin cancer) diagnosed or treated by a medical
professional, or do you require assistance (from anyone) with activities of daily living such as bathing,
dressing, eating or toileting?