Health & Well-Being

Click Health Behaviors in the Health & Well-Being section.
Select a response for ‘In the past three months have you smoked cigarettes or used any form of tobacco (e.g. chew, dip, cigars, hookah, and/or e-cigarettes)?’
Select a response for ‘Have you ever ridden in a car driven by someone (including yourself) that was high or was using alcohol or drugs?’
Select a response for ‘Does anyone in your home take opioids for an ongoing medical condition? (OxyContin, Hydrocodone, Codeine)’
Select Yes or No for ‘Do you lock your opioid medications in a medicine cabinet or other locked location?’
Select Yes or No for ‘Do you have a smoke detector in your home?’
Select Yes or No for ‘Do you have gas heating or appliances in your home?’
Select Yes or No for 'Do you have a carbon monoxide detector in your home?'
Click Save.

Select Yes or No for 'Was a Nursing Facility Level of Care (NFLOC) Performed?
1. If yes, select a date from the date calendar.
2. If yes, select the NFLOC status.
Click Caregiver in the Health & Well-Being section.
Select Yes or No for ‘Do you have a caregiver that comes into the home, because of a health care problem, to provide you with assistance?’
Select Relative, Friend, or Agency for ‘Is caregiver a relative, friend, or from an agency?’
Type in a response for Caregiver/Agency Name.
Type in a number for Caregiver/Agency phone number.
Type in a response for Caregiver/Agency Specialty.
Select Per Day or Per Week for ‘How many hours per day/week does caregiver come into your home?’. Then, type in a response.
Type in a response for ‘What items does your caregiver help with?’
Select Yes or No for ‘Do you need more help than you are receiving?’
1. If Yes, type in an explanation.

Click ADL / IADL in the Health & Well-Being section.
For each activity:
1. Select the level of Independence and Yes or No for Receiving Help or Additional Help Needed.
Click Save.

Click Sleep in the Health & Well-Being section.
Type in a response for ‘On average how many hours of sleep do you get in a 24-hour period’.
Select Yes or No for ‘Do you feel your sleep is restful?’

Click Employment in the Health & Well-Being section.
Select a response for ‘What is your current type of employment?’ from the ‘Employed – Full time’ – ‘Not in labor force’ scale. Select ‘Prefer not to answer’ if appropriate.
1. If Not Employed, select a response(s) for question 1a. Select all that apply.
2. If Employed, type in a response for question 1b.
Click Save.

Click D.M.E. in the Health & Well-Being section.
Select a response from the Have – Don’t Need scale for any of the listed medical equipment (questions 1-23).
1. Click the teal, column-heading buttons in order to select the same response for questions 1-23. The select-all functionality can be used as a starting point if nearly all the answers will be the same.
Select Yes or No for ‘Do you have other adaptive equipment that is not listed above?’
1. If Yes, type in a description.
Select Yes or No for ‘Do you want other adaptive equipment that is not listed above?’
1. If Yes, type in a description.
Click Save.

Click Legal in the Health & Well-Being section.
Select Yes or No for ‘Do you have an advance directive and/or living will?’. Select ‘Don’t Know’ if appropriate.
1. If Yes, select Yes or No for ‘Do you have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Do you have a psychiatric advance directive?’. Select ‘Don’t Know’ if appropriate.
1. If Yes, select Yes or No for ‘Do you have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Have you given Power of Attorney (POA) to someone?’.
1. If Yes, type in a response for whom.
2. If Yes, select Yes or No for ‘Do you have a copy of your POA to put in your record?’
Select Yes or No for ‘Are you under a conservatorship?’
1. If Yes, enter who.
2. If Yes, select Yes or no for ‘Cam you get a copy of the paperwork?’

Select a response for ‘In the past six months, have you been arrested?’
Select a response for ‘In the past six months, were you the victim of any violent crimes, such as assault, rape, mugging, or robbery?’

Click Safety/Injuries in the Health & Well-Being section.
Select Yes or No for 'Do you have a gun/firearm in the home?'
1. If yes, answer 1a and 1b
Select Yes or No for ‘During the past 12 months did you smoke any marijuana or hashish?’
Select Yes or No for ‘During the past 12 months did you use anything else to get high (includes illegal drugs, over-the-counter and prescription drugs, and things you sniff or huff)?'
If Yes was chosen for either question regarding the use of drugs, answer the following. Otherwise, leave blank.
1. Select Yes or No for ‘Do you use drugs to relax, feel better about yourself, or fit in?’
2. Select Yes or No for ‘Do you ever use drugs while you're by yourself, alone?’
3. Select Yes or No for ‘Have you ever gotten into trouble while you were using drugs?’
4. Select Yes or No for ‘Do you ever forget things you did while using drugs?’
5. Select Yes or No for ‘Does your family or friends ever tell you that you should cut down on your drug use?’

Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover food?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover clothing?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover housing?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover traveling around to get things, shopping, medical appointments, or visiting friends or relatives?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover social activities like movies or eating in restaurants?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover Heating, air conditioning, water, electricity, gas?’
Select Yes or No for ‘Are you currently receiving any governmental financial support?’
Select Yes or No for ‘Do you have questions you would like to discuss with your provider?’
Select Yes or No for ‘Do you know what benefits are available to you?’
Select Yes or No for ‘Do you feel your benefits meet your needs?’

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