HEALTH STATUS / VITAL SIGNS (continued) Caffeine Use?  No  Yes  Unknown Caffeine Use Comments: (Include duration and frequency per client response).  No  Yes  Unknown Has Gambling Ever Interfered With the Quality of Your Life? Gambling Comments: (Include duration and frequency per client response. Include financial / personal losses as a result of gambling habit). Pain Assessment Do You Have Any Pain or Discomfort?  No  Yes  Unknown (Complete manual / paper pain assessment) Pain Comments: (Include pain location, duration, frequency and how it may interfere with quality of life). Sleep Pattern Current Sleep Pattern: Difficulty falling asleep Enuresis Insomnia      Nightmares  Requires sleeping aid (specify) Sleep apnea Sleep walk Walking during night    None Other   (specify) Sleep Aid Note: (List any medications, devices, etc. that are required as an aid in sleeping). Sleep Comments: (How long since slept)? (Include responses and information obtained from previous hospitalization records). client’s Nutrition Nutrition Issues: Appetite Loss Decubitus  3 days)  (50%<intake Difficulty chewing / Swallowing / Choking Food Allergies    High Cholesterol / Triglycerides  History of anorexia  History of bulimia  History of polydipsia  HIV  Insulin dependent diabetes Kidney disease Morbid obesity   Non-insulin dependant diabetes Pregnancy    Tube feedings  Use of anticoagulant  Wasting appearance Use of MAO inhibitor IBW) 10# loss / Gain  (<20% Other  (specify) Nutrition Comments: (Indicate duration of issues noted with current / past effective / non-effective treatments if known). Current Diet: Nutrition Special Needs / Supplements: (Indicate frequency of supplements and any specific food / drink items preferred). 4
HEALTH STATUS / VITAL SIGNS (continued) Caffeine Use?  No  Yes  Unknown Caffeine Use Comments: (Include duration and frequency per client response). Has Gambling Ever Interfered With the Quality of Your Life?  No  Yes  Unknown Gambling Comments: (Include duration and frequency per client response. Include financial / personal losses as a result of gambling habit). Pain Assessment Do You Have Any Pain or Discomfort? (Complete manual / paper pain assessment)  No  Yes  Unknown Pain Comments: (Include pain location, duration, frequency and how it may interfere with quality of life). Sleep Pattern Current Sleep Pattern:  Difficulty falling asleep   Sleep apnea  None  Enuresis  Nightmares  Sleep walk  Other (specify)  Insomnia  Requires sleeping aid (specify)  Walking during night Sleep Aid Note: (List any medications, devices, etc. that are required as an aid in sleeping). Sleep Comments: (How long since slept)? (Include client’s responses and information obtained from previous hospitalization records). Nutrition Nutrition Issues:  Appetite Loss (50%<intake 3 days)  Difficulty chewing / Swallowing / Choking  High Cholesterol / Triglycerides  History of bulimia  HIV  Kidney disease  Non-insulin dependant diabetes  Tube feedings  Use of MAO inhibitor  Other (specify)  Decubitus  Food Allergies  History of anorexia  History of polydipsia  Insulin dependent diabetes  Morbid obesity  Pregnancy  Use of anticoagulant  Wasting appearance (<20% IBW) 10# loss / Gain Nutrition Comments: (Indicate duration of issues noted with current / past effective / non-effective treatments if known). Current Diet: Nutrition Special Needs / Supplements: (Indicate frequency of supplements and any specific food / drink items preferred). 4
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