Home Safety Checklist for All Homes Except CILA Homes
Acute pain? Nausea? Vomiting? Diarrhea? Weight loss? Abdominal gas, cramping, bloating or pain? Dizziness? Shortness of breath? Headache? Sensitivity to light? Stiff neck? Sore throat? Disrupted sleep? Fatigue? Itching? Thoughts of self-harm? *C = Current; Hx = Historical. Medication Yes No Notes/Comments 1. Prescription medication? (If yes ... ................
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