Allergy severe or life threatening High cholesterol, hypercholesterolemia, or hyperlipidemia –  Arthritis (osteoarthritis or rheumatoid arthritis) Kidney disease requiring dialysis  Asthma Osteoporosis or osteopenia  Auto immune disorder (rheumatoid arthritis, Parkinson’s disease  multiple sclerosis, lupus, etc.) Pregnancy  Blindness no functional eyesight Pressure ulcer –  Cancer Pulmonary condition (emphysema, COPD,  Chronic constipation or diarrhea pulmonary Deafness no functional hearing Severe scoliosis –  Dementia or Alzheimer’s disease Sleep apnea  Dental or gum disease Stroke or CVA  Diabetes oral medication required Substance current – –  Diabetes injected medication required Substance abuse history of – –  Dysphagia (swallowing disorder) Hyperthyroid, hypothyroid, or thyroid disease  Eating disorder (anorexia or bulimia) Over weight  Epilepsy or seizure disorder Under weight  Foot or nail condition requiring podiatrist care  GERD, acid reflux, or reflux esophagitis Other:  condition Other:  Check all of the following which currently apply: Requires food or liquid to be in particular consistency or size (for ex., chopped into specific pieces, ground up, pureed, thickened, etc.). Describe: Food consistency requirement change within past 3 months. Describe: Medically prescribed special diet (for ex., diabetic, low salt, high/low calorie, etc.). Describe: Unusual food preferences or food aversion. Describe: History or risk of dehydration History or risk of choking (swallowing risk factors include coughing during or meals, excessive throat clearing during or after meals, or gagging on food or liquids) Currently smokes Two or more falls within past 3 months Hands on assistance or close supervision required to use stairs within his/her residence Tactile kinesthetic issues (for example, hypersensitivity to touch and other sensory stimulation such as light or sound)
Allergy – severe or life threatening  High cholesterol, hypercholesterolemia, or hyperlipidemia Arthritis (osteoarthritis or rheumatoid arthritis)  Kidney disease requiring dialysis Asthma  Osteoporosis or osteopenia Auto immune disorder (rheumatoid arthritis,  Parkinson’s disease multiple sclerosis, lupus, etc.)  Pregnancy Blindness – no functional eyesight  Pressure ulcer Cancer  Pulmonary condition (emphysema, COPD, Chronic constipation or diarrhea pulmonary Deafness – no functional hearing  Severe scoliosis Dementia or Alzheimer’s disease  Sleep apnea Dental or gum disease  Stroke or CVA Diabetes – oral medication required  Substance – current Diabetes – injected medication required  Substance abuse – history of Dysphagia (swallowing disorder)  Hyperthyroid, hypothyroid, or thyroid disease Eating disorder (anorexia or bulimia)  Over weight Epilepsy or seizure disorder  Under weight Foot or nail condition requiring podiatrist care  GERD, acid reflux, or reflux esophagitis  Other: condition  Other: Check all of the following which currently apply: Requires food or liquid to be in particular consistency or size (for ex., chopped into specific pieces, ground up, pureed, thickened, etc.). Describe: Food consistency requirement change within past 3 months. Describe: Medically prescribed special diet (for ex., diabetic, low salt, high/low calorie, etc.). Describe: Unusual food preferences or food aversion. Describe: History or risk of dehydration History or risk of choking (swallowing risk factors include coughing during or meals, excessive throat clearing during or after meals, or gagging on food or liquids) Currently smokes Two or more falls within past 3 months Hands on assistance or close supervision required to use stairs within his/her residence Tactile kinesthetic issues (for example, hypersensitivity to touch and other sensory stimulation such as light or sound)
Part-B-Home-Support-Frequency-Tool.docx