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style="background-color:#CCCCFF"> 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... #SNform.Home_Safety_Assess#

style="background-color:#CCCCFF"> 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

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checked> listless checked> apathetic checked> cachectic checked> underweight checked> overweight checked> poor muscle tone checked> paresthesia checked> anorexia checked> indigestion

checked> tongue swelling, beefy checked> absent teeth checked> pal conjunctivae checked> nails spoon-shaped checked> dependent edema checked> prominent scapula checked> Asymptomatic checked> Other... #SNform.M0250_Assess#

style="background-color:#CCCCFF"> 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...

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checked> pain level 0 (low) checked> pain level 1 (low) checked> pain level 2 (low) checked> pain level 3 (med) checked> pain level 4 (med) checked> pain level 5 (med)

checked> pain level 6 (med) checked> pain level 7 (high) checked> pain level 8 (high) checked> pain level 9 (high) checked> pain level 10 (high) checked> Other... #SNform.M0420_Assess#

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checked /> Throbbing checked /> Stabbing checked /> Sharp

checked /> Aching checked /> Burning checked /> Numb

checked /> Shooting checked /> Not Applicable checked /> Other... #SNform.Emergent_Care_M0830#

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checked> at rest checked> with minimal activity checked> with moderate activity checked> with strenuous activity

checked>Not Applicable

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checked> 1 checked> 2 checked> 3 checked> 4 checked> 5

checked> 6 checked> 7 checked> 8 checked> 9 checked> 10

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checked> 30 minutes checked> 1 hour checked> 2 hours checked> 3 hours checked> 4 hours

checked> 6 hours checked> 12 hours checked> 24 hours checked> more than 24 hours checked> Not Applicable

style="background-color:CCCCFF"> checked /> physical activity
checked /> disease process
checked /> Not Applicable

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checked /> Poor skin turgor checked /> Color pale checked /> Color jaundice checked /> Color cyanotic checked /> Sweaty skin

checked /> Dry skin checked /> Bruise(s) checked /> Rash(es) checked /> Asymptomatic checked /> Other... #SNform.M0440_Assess#

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checked /> Dyspnea, shortness of breath checked /> Breath sounds not clear checked /> Sputum not clear,Scant, Watery checked /> Dependent edema checked /> High blood pressure checked /> bnormal lab results checked /> Palpitations, diaphoresis checked /> Dizziness, headaches checked /> Weakness/fatigue checked /> Nosebleeds checked /> Asymptomatic

checked /> Other... #SNform.M0490_Assess#

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checked /> Urine color not pale yellow checked /> Urine odor not faint checked /> Excoriation of surrounding skin checked /> Abnormal urine frequency checked /> Abnormal lab results checked /> Genital discharge checked /> Genital lesions checked /> Genital inflamm checked /> Asymptomatic

checked /> Other... #SNform.M0520_Assess#

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checked /> Bowel sounds not soft gurgling 5-35/min checked /> Diarrhea checked /> Constipation checked /> Excoriation of surrounding skin checked /> Abnormal stool lab checked /> Asymptomatic

checked /> Other... #SNform.M0540_Assess#

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checked /> Flatulence checked /> Constipation checked /> Diarrhea

checked /> Excoriation of surrounding skin checked /> Other... #SNform.M0550_Assess#

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10 - 14 seconds">checked /> PT <> 10 - 14 seconds 22 - 45 seconds">checked /> PTT <> 22 - 45 seconds checked /> Breath sounds not clear checked /> Sputum not clear, scant, watery checked /> Tremors, handgrip weakness checked /> Headaches checked /> Aphasia checked /> Pupils fixed checked /> Hallucinations checked /> Stupor checked /> Short term memory limits checked /> Long term memory limits checked /> Asymptomatic

checked /> Other... #SNform.M0610_Assess#

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checked /> Disoriented checked /> Anxious checked /> Confused checked /> Depressed checked /> Behavioral problems checked /> Grieving checked /> Inability to cope

checked /> Other... #SNform.Housekeeping_M0750p#

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checked /> Abnormal gait and station checked /> Limited range of motion checked /> Limited muscle strength checked /> Impaired coordination checked /> Multiple falls in the last 6 months checked /> Weakness checked /> Deformities checked /> Scoliosis checked /> Sydney Palm Crease checked /> Simian Crease checked /> Kyphosis checked /> Trendelenburg Gait checked /> ASYMPTOMATIC

checked />Other #SNform.Meal_Prep_M0720#