This government document is issued by Department of Aging for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:p5rt2izphxk&q=https://www.aging.pa.gov/organization/licensing-and-monitoring/Documents/SAMPLE%2520Intake%2520Screening%2520Form%252009-24-2014.pdf&sa=U&ved=2ahUKEwiepvfa7a_8AhWdRaQEHSN1BB84MhAWegQIABAC&usg=AOvVaw0DxYPspTmyKYsvrOcDz1m9