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Evaluation

Are you screening a person for admission to a nursing facility?

Has the patient been placed in a nursing home within the past 5 years?

Has the patient experienced a functional decline in the past 90 days?

Number of days that the person has left home during the past week

Number of daily episodes of urinary incontinence

Number of occasions that hands-on guidance or physical assistance was required for each activity during the last 7 days:

• dressing

times

• personal hygiene

times

• eating

times

• toilet use

times

• bathing

times

Severe neurological disorder(s)

Results

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