M1033M1032 Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (mark all that apply)

checked> 1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) checked> 2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months checked> 3 - Multiple hospitalizations (2 or more) in the past 6 months checked> 4 - Multiple emergency department visits (2 or more) in the past 6 months checked> 5 - Decline in mental, emotional, or behavioral status in the past 3 months checked> 6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months checked> 7 - Currently taking 5 or more medications checked> 8 - Currently reports exhaustion checked> 9 - Other risk(s) not listed in 1 - 8 checked> 10 - None of the above

M1034 Overall Status: Which description best fits overall status? (Check one)

checked> 0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient's age). checked> 1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient's age). checked> 2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death. checked> 3 - The patient has serious progressive conditions that could lead to death within a year. checked> UK - The patient's situation is unknown or unclear.

M1036 Risk Factors characterizing patient: (mark all that apply.)

checked> 1 - Smoking checked> 2 - Obesity checked> 3 - Alcohol dependency checked> 4 - Drug dependency checked> 5 - None of the above checked> UK - Unknown

Comments

Patient's Own Words: