receiving_screening_matrix.xlsx

	A	B	C
1	Minnesota Rules 2911.5800, Subp. 6	NCCHC \| J-E-02	ACA/CAC \| 5-ACI-6A-21

2	Inquiry into:
3	Current illness and health problems including	Current and past illnesses, health conditions	Current illness and health problems
4	dental emergencies	Dental problems (decay, gum disease, abscess)	dental problems
5	infectious diseases		communicable diseases
6			mental illness
7		Past infectious disease	Any past history of serious infections or communicable illness
8	Medication taken	Prescription medications (including type, amount, and time of last use)
9		Allergies
10		Dietary needs
11	Special health requirements	Special health requirements
12		hearing impairment
13		visual impairment
14		wheelchair
15		walker
16		sleep apnea machine
17	Use of alcohol and other drugs that include	Legal and illegal drug use	Use of alcohol and other drugs, including
18	types of drugs used	type	type(s) of drugs used
19	mode of use		mode of use
20	amounts used	amount	amounts used
21	frequency used		frequency used
22	date or time of last use	time of last use	date or time of last use
23	history of problems that may have occurred after ceasing use, for example, convulsions	history of prior withdrawal symptoms	history of any problems that may have occurred after ceasing use (for example, convulsions)
24	Past and present treatment or hospitalization for mental illness or attempted suicide	Past or current mental illness, including hospitalizations	Any past history of mental illness, thoughts of suicide or self-injurious behavior attempts
25	(cf. 2911.1300: signs of suicide risk and suicide precautions; 2911.1900: written suicide prevention plan)	History of or current suicidal ideation
26	Other health problems designated by the health authority	Other health problems as specified by the responsible physician	Other health problems designated by the responsible physician
27		Possible, current , or recent pregnancy	Possibility of pregnancy and history of problems
28	Signs and symptoms of active tuberculosis to include	Recent communicable illness symptoms
29	weight loss	weight loss, loss of appetite
30	night sweats	night sweats
31	persistent cough lasting three weeks or longer	chronic cough
32	coughing up blood	coughing up blood
33	low grade fever	fever
34	fatigue	lethargy, weakness
35	chest pain
36	prior history of active tuberculosis disease
37	results of previous tuberculin skin or blood testing
38	Observations of:
39	Behavior that includes	Behavior	Behavior
40	state of consciousness	state of consciousness (e.g., alert, responsive, lethargic)	state of consciousness
41	mental status	(mental status)	mental status
42		delusions
43		hallucinations
44		communication difficulties
45		speech
46		posture
47		disorganization
48		memory defects
49		depression
50	appearance	appearance (e.g., anxious, disheveled)	appearance
51	conduct	disorderly, appropriate, insensible	conduct
52	tremor	tremor	tremor
53	sweating	sweating	sweating
54		Ease of movement (e.g., gait)	Ease of movement
55	Body deformities	Body deformities	Body deformities
56		Breathing (e.g., persistent cough, hyperventilation)
57		Skin	Skin
58		rashes	rashes
59		infestations	infestations
60		scars
61		tattoos	recent tattoos
62		needle marks or other indications of drug abuse	needle marks, or other indications of drug use
63		evidence of self-mutilaton
64	Trauma markings		Trauma markings
65	Body piercings
66	Bruises	Bruises	Bruises
67	Lesions	Lesions	Lesions
68	Jaundice	Jaundice	Jaundice
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