checked> 1 - Intravenous or infusion therapy (excludes TPN) checked> 2 - Parenteral nutrition (TPN or liquids) checked> 3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, etc) checked> 4 - None of the above

checked> Overweight checked> Underweight checked> Recent significant weight loss checked> Recent significant weight gain checked> Problems with chewing, swallowing checked> Problems with teeth/dentures checked> Asymptomatic checked> Other...

checked> Hyperglycemia: thirst, tiredness, apathy, increased sleeping checked> Hypoglycemia: hunger, dizziness, shaking, nervousness checked> Sugar in urine checked> Serum <> between 65 - 99 mg/dL checked> Asymptomatic checked> Other...

checked> Unsafe stairs and/or doorways checked> Rugs, cords and/or furniture causing safety risk checked> Inadequate heating and /or cooling checked> Unsafe appliances checked> Inadequate sanitation and/or plumbing checked> Inadequate refrigeration checked> Presence of insects and/or rodents checked> Inadequate smoke detectors checked> O2 in use without precautions checked> HOME HAS NO HAZARDS checked> Other...