Instructions for Health/Safety/ Risk section: Use the checklist to initiate conversations about health, medical, supervision and other supports the person may need. Incorporate into the plan of care the services and supports needed to keep the person safe and mitigate risk. Health/ Safety/ Risk Medical Current History Medical Current History Asthma Y N Y N Diabetes Y N Y N Y N Y N Y N Y N Frequent Colds Pneumonia Respiratory/Lung/ Breathing Problems Y N Y N Uses Catheter, colostomy Y N Y N Feeding Issues Y N Y N GER (gastro esophageal reflux) Y N Y N Y N Y N Y N Y N Allergies At risk for Aspiration (Medication, Food, Seasonal) Y N Y N Ear infections Y N Y N Uses G-Tube Y N Y N Y N Y N Frequent Headaches Coughs or chokes while eating or drinking Y N Y N Serious Skin condition Y N Y N Someone else puts food/liquids in your mouth Y N Y N Y N Y N Hypertension/ High Blood Pressure Mechanically altered diet (thickened, chopped/ puréed) Medically Prescribed Diet Y N Y N Heart/ Circulatory Y N Y N (fat, sodium, cholesterol) Extreme food/ liquid seeking behavior that may Y N Y N Stomach/Digestive Y N Y N cause injury (Prader Willi Syndrome) Dehydration Risk/ Regularly Refuses Liquids Y N Y N Needs assistance ambulating Y N Y N Y N Y N Y N Y N Constipation Seizure Disorder Routinely takes bowel medications, Requires suppository or enema, Loss of Consciousness/Gran Mal, Absence/Petit Mal, Routinely takes fiber Other Seizure Kidney/Urinary Y N Y N Other Medical Not Listed : Y N Y N Hepatitis B Y N Y N I do not have any identified medical Y N Y N conditions. Use of Adaptive Equipment Current History Use of Adaptive Equipment Current History Y N Y N Y N Y N Wheelchair Elastic Stocking (Manual requires assistance, manual self-propels, motorized requires assistance, motorized self-propels) Eyeglasses Y N Y N Modified Eating Utensils Y N Y N Walker/Crutches/Cane Y N Y N PERS-Personal Emergency Response System Y N Y N
Instructions for Health/Safety/ Risk section: Use the checklist to initiate conversations about health, medical, supervision and other supports the person may need. Incorporate into the plan of care the services and supports needed to keep the person safe and mitigate risk. Health/ Safety/ Risk Medical Current History Medical Current History Asthma Y N Y N Diabetes Y N Y N Frequent Colds Y N Y N Pneumonia Y N Y N Respiratory/Lung/ Breathing Problems Y N Y N Uses Catheter, colostomy Y N Y N Feeding Issues Y N Y N GER (gastro esophageal reflux) Y N Y N At risk for Aspiration Y N Y N Allergies (Medication, Food, Seasonal) Y N Y N Uses G-Tube Y N Y N Ear infections Y N Y N Coughs or chokes while eating or drinking Y N Y N Frequent Headaches Y N Y N Someone else puts food/liquids in your mouth Y N Y N Serious Skin condition Y N Y N Mechanically altered diet (thickened, chopped/ puréed) Y N Y N Hypertension/ High Blood Pressure Y N Y N Medically Prescribed Diet (fat, sodium, cholesterol) Y N Y N Heart/ Circulatory Y N Y N Extreme food/ liquid seeking behavior that may cause injury (Prader Willi Syndrome) Y N Y N Stomach/Digestive Y N Y N Dehydration Risk/ Regularly Refuses Liquids Y N Y N Needs assistance ambulating Y N Y N Constipation Routinely takes bowel medications, Requires suppository or enema, Routinely takes fiber Y N Y N Seizure Disorder Loss of Consciousness/Gran Mal, Absence/Petit Mal, Other Seizure Y N Y N Kidney/Urinary Y N Y N Other Medical Not Listed : Y N Y N Hepatitis B Y N Y N I do not have any identified medical conditions. Y N Y N Use of Adaptive Equipment Current History Use of Adaptive Equipment Current History Wheelchair (Manual requires assistance, manual self-propels, motorized requires assistance, motorized self-propels) Y N Y N Elastic Stocking Y N Y N Eyeglasses Y N Y N Modified Eating Utensils Y N Y N Walker/Crutches/Cane Y N Y N PERS-Personal Emergency Response System Y N Y N
ihp%20006%20DDD%20adaptive%20behavior%20summary.docx