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Patient Questionnaire one

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Social History


Social History

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For Example: Balanced Diet = Combination of fruits, vegetables, grains, low-fat dairy each day. Minimal Salts = Less than one teaspoon per day. Bad Fats = Fried Food, Fast Food, packaged foods from a box.
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Malnutrition


Malnutrition

The responses to the following questions should consider the patient response and provider assessment:
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Smoking History


Smoking History

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Drug History


Drug History

If Illegal Drug Use, please select drug(s) below:
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If any drug(s) selected, please select if applicable:

Alcohol History


Alcohol History

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Select if applicable in addition to use, abuse or dependency:
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Self-Assessment


Self-Assessment

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Depression Assessment


Depression Assessment

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Fall Risk & Home Safety


Fall Risk & Home Safety

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If Yes to Fall:
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Activities of Daily Living Scale


Activities of Daily Living Scale

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If yes, check all that apply:
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