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Please tick (√)one onlyIf yes,please tick (√)Health problemsYes, oftenYes, sometimesNo problemNot relevantDo you receivehelp for <strong>this</strong>problemcurrently?[ A ] Problem with eating, drinking orappetite[ B ] Problem sleeping[ C ] Mobility problems like getting up,walking[ D ] Difficulty with daily life activities, liketaking care of myself[ E ] Difficulty doing household chores[ F ] Difficulty taking care of my children[ G ] Difficulty taking treatments regularly[ H ] Problems with drugs or alcohol[ I ] Problems with sex[ J ] Others, please specify______________________________17b. Please tell us what financial problems you experience currently as a result of your HIVstatus. Please tick (√) all that apply.Please tick (√)one onlyIf yes,please tick (√)Financial problemsYes, oftenYes, sometimesNo problemNot relevantDo you receivehelp for <strong>this</strong>problemcurrently?[ A ] Housing rent / mortgage payments[ B ] No fixed place to stay[ C ] Utility bills (electricity, water, phone)payments[ D ] Buying food stuff153

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