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Make a decision               Does your patient safely leave home frequently for non-medical purposes? Leave home to participate in therapeutic,psychological or medical treatment in an adult day care program, licensed or certified by the state       YES NO Not considered Homebound Does your patient require assistance when leaving home? The use of a cane, wheelchair or assistance to leave the home • A limited ability for ambulation due to pain and/or weakness • Severe heart disease in a patient who must avoid stress • A physician has determined outings are medically contraindicated     YES NO Requires the assistance of another person • May require the use of a cane, walker or wheel chair • Limited ability to walk due to pain or weakness • A psychiatric condition that manifests with a refusal to leave home or that makes it unsafe to leave home unattended Does your patient endure considerable and taxing effort when leaving home? Patient not considered homebound     YES   Patient is considered Homebound