我想问您一些问题,以便计划向您和您的家人提.PDF

您好。 我想问您一些问题，以便计划向您和您的家人提 供服务。 Simplified Chinese Hello. There are some questions I need to ask to help plan care for you or your family member. 我们在这里写出了问题。我们还给出了大多数 问题的可选答案。请指向正确答案，或者写出 正确答案，以便我们开始计划为您提供服务。 如果您对问题不明白，或者不知道怎样回答， 请指向问题表上的“不确定”。 Simplified Chinese I have each question written for you. We will give you answer choices for most questions. Please point to the answer or write an answer so we can start to plan your care. If you are not sure about a question or how to answer the question, please point to “Not sure” on the sheet. 您是否能告诉我您的姓名？ 否 不确定 是 Simplified Chinese Can you tell me your name? No Not sure Yes 您是否能把您的姓名写在这张纸上？ 否 不确定 是 Simplified Chinese Can you write your name on this paper for me? No Not sure Yes 您是一个人来我们机构的吗？ 否 不确定 是 Simplified Chinese Did you come here alone? No Not sure Yes 是否有亲友与您一起来？ 否 不确定 是 Simplified Chinese Do you have other family member or friends with you? No Not sure Yes 如果有，是否能说出或写下他们的姓名和年龄？ 否 不确定 是 Simplified Chinese If yes, can you tell me or write their names and ages? No Not sure Yes 您本人是否需要服务？ 否 不确定 是 Simplified Chinese Are you the person that needs help with care? No Not sure Yes 如果不是，请写下需要服务者的姓名。 不确定 Simplified Chinese If not, please write their name. Not Sure 您是此人的什么人？ 父母 伴侣 监护人 其他家庭成员 配偶 朋友或邻居 子女 没有关系 兄弟或姐妹 Simplified Chinese How are you related to this person? Parent Partner Guardian Other family member Spouse Friend or Neighbor