Comments: Nutrition/Hydration Screening Check if you have experienced: Any weight loss or gain of 10 pounds or more in the past three months Change in appetite Are you experiencing any other problems eating or drinking? Pain Screening Do you have any ongoing pain problems? No Yes If yes, Medical Staff completes pain section below. Joint The Commission For Women Only Currently pregnant? Receiving pre-natal healthcare? No Yes If yes, indicate provider: No Yes - If yes, expected delivery date: – Any significant pregnancy history? Are you currently breastfeeding? No Yes No Yes If yes, explain: – Menstruation Last menstrual Period Date: Pre-menstrual symptoms: No Yes Menstrual Pain: No Yes Polycystic Syndrome? No Yes No Yes If yes, Indicate provider: Menstrual Irregularities: For Children Only
Comments: Nutrition/Hydration Screening Check if you have experienced: Any weight loss or gain of 10 pounds or more in the past three months Change in appetite Are you experiencing any other problems eating or drinking? The Joint Commission Pain Screening Do you have any ongoing pain problems? No Yes If yes, Medical Staff completes pain section below. For Women Only Currently pregnant? No Yes - If yes, expected delivery date: Are you currently breastfeeding? No Yes Receiving pre-natal healthcare? No Yes – If yes, indicate provider: Any significant pregnancy history? No Yes – If yes, explain: Menstruation Last menstrual Period Date: Menstrual Pain: No Yes Menstrual Irregularities: No Yes Pre-menstrual symptoms: No Yes Polycystic Syndrome? No Yes If yes, Indicate provider: For Children Only