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Demographic information:  ZIP code of prior primary residence.

Demographic information:  residential history prior to entry - prior stay at this nursing home.

Demographic information:  residential history prior to entry - prior stay in other nursing home.

Demographic information:  residential history prior to entry - other residential facility.

Demographic information:  residential history prior to entry - MH/psychiatric setting.

Demographic information:  residential history prior to entry - MR/DD setting.

Demographic information:  residential history prior to entry - none of above

Demographic information:  lifetime occupation(s).

Demographic information:  education (highest level completed).

Demographic information:  primary language

Demographic information:  if other (language), specify.

Demographic information:  metal health history

Customary routine:  cycle of daily events - stays up late at night

Customary routine:  cycle of daily events - naps regularly during day

Customary routine:  cycle of daily events - goes out one or more days a week.

Customary routine:  cycle of daily events - stys busy with hobbies/fixed routine.

Customary routine:  cycle of daily events - spends most time alone or watching TV

Customary routine:  cycle of daily events - moves independently indoors.

Customary routine:  cycle of daily events - use of tobacco daily.

Customary routine:  cycle of daily events - none of above.

Customary routine:  eating patterns - distinct food preferences.

Customary routine:  eating patterns - eats between meals most days.

Customary routine:  eating patterns - use of alcohol weekly.

Customary routine:  eating patterns - none of above.

Customary routine:  ADL patterns - in bedclothes much of day.

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