{"id":7618,"date":"2021-04-22T13:03:27","date_gmt":"2021-04-22T18:03:27","guid":{"rendered":"https:\/\/uamscaregiving.org\/springdale\/?page_id=7618"},"modified":"2026-02-06T13:08:11","modified_gmt":"2026-02-06T19:08:11","slug":"epst","status":"publish","type":"page","link":"https:\/\/uamscaregiving.org\/springdale\/epst\/","title":{"rendered":"Ending Point Self Test &#8211; WWE"},"content":{"rendered":"<p>All reporting of your responses will be in the aggregate; no individually identifiable information will be shared.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_156' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_156'  action='\/springdale\/wp-json\/wp\/v2\/pages\/7618' data-formid='156' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_156' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_156_23\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_23\" ><label class='gfield_label gform-field-label' for='input_156_23'>What is today&#039;s date?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_156_23'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_156_23_dmessage' name='input_23' id='input_156_23' type='text' value='04\/25\/2026' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_156_23_date_format gfield_description_156_23\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_156_23_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_156_23' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_156_18\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_18\" ><label class='gfield_label gform-field-label' for='input_156_18'>Enter your birthday<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_156_18'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_156_18_dmessage' name='input_18' id='input_156_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_156_18_date_format gfield_description_156_18\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_156_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_156_18' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_156_41\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_41\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_156_41'>\n                            \n                            <span id='input_156_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_156_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_156_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_156_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_156_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_156_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/li><li id=\"field_156_92\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_92\" ><label class='gfield_label gform-field-label' >Did you see any improvement from your Starting Point Self-test?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_92'>\n\t\t\t<li class='gchoice gchoice_156_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_156_92_0'    \/>\n\t\t\t\t<label for='choice_156_92_0' id='label_156_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='No'  id='choice_156_92_1'    \/>\n\t\t\t\t<label for='choice_156_92_1' id='label_156_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_93\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_93\" ><label class='gfield_label gform-field-label' for='input_156_93'>What comments do you have regarding your improvement?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_156_93' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_156_87\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_87\" >______________________________________________________________________________________________________________________<\/li><li id=\"field_156_72\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_72\" ><label class='gfield_label gform-field-label' for='input_156_72'>PAIN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_156_72'>Please enter the number (no decimals) that best describes how much physical pain your arthritis caused during the past week.<br><br>\n\n<i><strong>Zero (0) is \"no pain at all\" -- Ten (10) is \"the worst pain possible\"<\/strong><\/i><\/div><div class='ginput_container ginput_container_number'><input name='input_72' id='input_156_72' type='number' step='any' min='0' max='10' value='0' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_156_72 gfield_description_156_72\" \/><div class='gfield_description instruction ' id='gfield_instruction_156_72'>Please enter a number from <strong>0<\/strong> to <strong>10<\/strong>.<\/div><\/div><\/li><li id=\"field_156_74\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_74\" ><label class='gfield_label gform-field-label' for='input_156_74'>FATIGUE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_156_74'>Please enter the number (no decimals) that best describes how much of a problem fatigue was for you during the past week.<br><br>\n\n<i><strong>Zero (0) is \"no problem\" -- Ten (10) is \"a major problem\"<\/strong><\/i><\/div><div class='ginput_container ginput_container_number'><input name='input_74' id='input_156_74' type='number' step='any' min='0' max='10' value='0' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_156_74 gfield_description_156_74\" \/><div class='gfield_description instruction ' id='gfield_instruction_156_74'>Please enter a number from <strong>0<\/strong> to <strong>10<\/strong>.<\/div><\/div><\/li><li id=\"field_156_90\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_90\" >______________________________________________________________________________________________________________________<\/li><li id=\"field_156_75\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_75\" ><strong>The following items are about activities you might do during a typical day.  Does your health status now <i>limit<\/i> you in the following activities? <\/strong><br><br>\n<i>For each item listed below choose the appropriate response for you<\/i><\/li><li id=\"field_156_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_55\" ><label class='gfield_label gform-field-label' >Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_55'>\n\t\t\t<li class='gchoice gchoice_156_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='1'  id='choice_156_55_0'    \/>\n\t\t\t\t<label for='choice_156_55_0' id='label_156_55_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='2'  id='choice_156_55_1'    \/>\n\t\t\t\t<label for='choice_156_55_1' id='label_156_55_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_55_2'>\n\t\t\t\t<input name='input_55' type='radio' value='3'  id='choice_156_55_2'    \/>\n\t\t\t\t<label for='choice_156_55_2' id='label_156_55_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_76\" ><label class='gfield_label gform-field-label' >Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_76'>\n\t\t\t<li class='gchoice gchoice_156_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='1'  id='choice_156_76_0'    \/>\n\t\t\t\t<label for='choice_156_76_0' id='label_156_76_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='2'  id='choice_156_76_1'    \/>\n\t\t\t\t<label for='choice_156_76_1' id='label_156_76_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_76_2'>\n\t\t\t\t<input name='input_76' type='radio' value='3'  id='choice_156_76_2'    \/>\n\t\t\t\t<label for='choice_156_76_2' id='label_156_76_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_82\" ><label class='gfield_label gform-field-label' >Lifting or carrying groceries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_82'>\n\t\t\t<li class='gchoice gchoice_156_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='1'  id='choice_156_82_0'    \/>\n\t\t\t\t<label for='choice_156_82_0' id='label_156_82_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='2'  id='choice_156_82_1'    \/>\n\t\t\t\t<label for='choice_156_82_1' id='label_156_82_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_82_2'>\n\t\t\t\t<input name='input_82' type='radio' value='3'  id='choice_156_82_2'    \/>\n\t\t\t\t<label for='choice_156_82_2' id='label_156_82_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_84\" ><label class='gfield_label gform-field-label' >Climbing several flights of stairs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_84'>\n\t\t\t<li class='gchoice gchoice_156_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='1'  id='choice_156_84_0'    \/>\n\t\t\t\t<label for='choice_156_84_0' id='label_156_84_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='2'  id='choice_156_84_1'    \/>\n\t\t\t\t<label for='choice_156_84_1' id='label_156_84_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='3'  id='choice_156_84_2'    \/>\n\t\t\t\t<label for='choice_156_84_2' id='label_156_84_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_86\" ><label class='gfield_label gform-field-label' >Climbing one flight of stairs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_86'>\n\t\t\t<li class='gchoice gchoice_156_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='1'  id='choice_156_86_0'    \/>\n\t\t\t\t<label for='choice_156_86_0' id='label_156_86_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='2'  id='choice_156_86_1'    \/>\n\t\t\t\t<label for='choice_156_86_1' id='label_156_86_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_86_2'>\n\t\t\t\t<input name='input_86' type='radio' value='3'  id='choice_156_86_2'    \/>\n\t\t\t\t<label for='choice_156_86_2' id='label_156_86_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_83\" ><label class='gfield_label gform-field-label' >Bending, kneeling, or stooping<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_83'>\n\t\t\t<li class='gchoice gchoice_156_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='1'  id='choice_156_83_0'    \/>\n\t\t\t\t<label for='choice_156_83_0' id='label_156_83_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='2'  id='choice_156_83_1'    \/>\n\t\t\t\t<label for='choice_156_83_1' id='label_156_83_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_83_2'>\n\t\t\t\t<input name='input_83' type='radio' value='3'  id='choice_156_83_2'    \/>\n\t\t\t\t<label for='choice_156_83_2' id='label_156_83_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_80\" ><label class='gfield_label gform-field-label' >Walking more than a mile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_80'>\n\t\t\t<li class='gchoice gchoice_156_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='1'  id='choice_156_80_0'    \/>\n\t\t\t\t<label for='choice_156_80_0' id='label_156_80_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='2'  id='choice_156_80_1'    \/>\n\t\t\t\t<label for='choice_156_80_1' id='label_156_80_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_80_2'>\n\t\t\t\t<input name='input_80' type='radio' value='3'  id='choice_156_80_2'    \/>\n\t\t\t\t<label for='choice_156_80_2' id='label_156_80_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_81\" ><label class='gfield_label gform-field-label' >Walking several hundred yards<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_81'>\n\t\t\t<li class='gchoice gchoice_156_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='1'  id='choice_156_81_0'    \/>\n\t\t\t\t<label for='choice_156_81_0' id='label_156_81_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='2'  id='choice_156_81_1'    \/>\n\t\t\t\t<label for='choice_156_81_1' id='label_156_81_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='3'  id='choice_156_81_2'    \/>\n\t\t\t\t<label for='choice_156_81_2' id='label_156_81_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_79\" ><label class='gfield_label gform-field-label' >Walking one hundred yards<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_79'>\n\t\t\t<li class='gchoice gchoice_156_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='1'  id='choice_156_79_0'    \/>\n\t\t\t\t<label for='choice_156_79_0' id='label_156_79_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='2'  id='choice_156_79_1'    \/>\n\t\t\t\t<label for='choice_156_79_1' id='label_156_79_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_79_2'>\n\t\t\t\t<input name='input_79' type='radio' value='3'  id='choice_156_79_2'    \/>\n\t\t\t\t<label for='choice_156_79_2' id='label_156_79_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_78\" ><label class='gfield_label gform-field-label' >Bathing or dressing yourself<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_156_78'>\n\t\t\t<li class='gchoice gchoice_156_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='1'  id='choice_156_78_0'    \/>\n\t\t\t\t<label for='choice_156_78_0' id='label_156_78_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='2'  id='choice_156_78_1'    \/>\n\t\t\t\t<label for='choice_156_78_1' id='label_156_78_1' class='gform-field-label gform-field-label--type-inline'>Yes, a little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_156_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='3'  id='choice_156_78_2'    \/>\n\t\t\t\t<label for='choice_156_78_2' id='label_156_78_2' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/li><\/ul><\/div><\/fieldset><\/li><li id=\"field_156_85\" class=\"gfield gfield--type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_156_85\" ><label class='gfield_label gform-field-label' for='input_156_85'>Your Physical Limitations score<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_85' id='input_156_85' type='text' step='any'   value='{Bathing or dressing yourself:78}+{Walking one hundred yards:79}+{Walking several hundred yards:81}+{Walking more than a mile:80}+{Bending, kneeling, or stooping:83}+{Climbing several flights of stairs:84}+{Lifting or carrying groceries:82}+{Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf:76}+{Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports:55}+{Climbing one flight of stairs:86}' class='medium'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_156' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_156\"]){return false;}  if( !jQuery(\"#gform_156\")[0].checkValidity || jQuery(\"#gform_156\")[0].checkValidity()){window[\"gf_submitting_156\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_156\"]){return false;} if( !jQuery(\"#gform_156\")[0].checkValidity || jQuery(\"#gform_156\")[0].checkValidity()){window[\"gf_submitting_156\"]=true;}  jQuery(\"#gform_156\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_156' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='156' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_156' value='WyJbXSIsIjFlM2IwZmFmODUyMmYyMjBjYzE2YTM0MTI1N2NkMmM5Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_156' id='gform_target_page_number_156' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_156' id='gform_source_page_number_156' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"139\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 156, 'https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_156').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_156');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_156').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_156').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_156').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_156').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_156').val();gformInitSpinner( 156, 'https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [156, current_page]);window['gf_submitting_156'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = 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