1. What is the sex of your patient?

2. Does your patient have shortness of breath?

3. Does your patient have congestive heart failure?

4. Does your patient have a condition or disease that causes fluctuation, instability or decline in their activities of daily living (ADL), cognitive, or behavioral status?

5. Does your patient leave more than 25% of their food uneaten?

6. The following items are from the Activities of Daily Living Long Form as used in the Minimum Data Set:

• Which of the following best describes how your patient moves and turns his or her body while in bed?

• Which of the following best describes how your patient moves between surfaces such as a bed and a chair?

• Which of the following best describes how your patient moves between locations such as from their room to the hallway outside their room?

• Which of the following best describes how your patient puts on, fastens, and takes off his or her every day clothing?

• Which of the following best describes how your patient eats and drinks or intakes nourishment (i.e. in the case of tube feeding)?

• Which of the following best describes how your patient uses a toilet, commode, bedpan, or urinal and transfers on and off the toilet?

• Which of the following best describes how your patient maintains personal hygiene, including combing hair, brushing teeth, washing and drying face and hands (but excluding baths and showers)?

7. Is your patient’s total ADL score (as shown above) less than the median ADL score from your patient’s Minimum Data Set? (If you divide your nursing home into a more functional half and less functional half, would your patient be in the more functional half?)

8. Does your patient have a BMI ≤ 23?BMI calculator

9. Does your patient have a history of cancer?

10. Is your patient confined to bed?

11. Does your patient have problems swallowing?

12. Does your patient display complete or frequent bowel incontinence?