Pre Screening For Long Term Care Pre-Screening InformationTobacco use in last 12 months:*nonecigarettescigarschewnicotine replacementif quit, last used: Month Day Year Height: Weight: Medical Conditions and Diagnosis (if possible):Treatment: (everything except medications, i.e. Chemotherapy, Psychotherapy, Radiation Treatment)Treatment Dates:Current Medications:What would you like to do next?* Submit, I'm finished Submit, and do another for same client Submit, and do another for a different client NameThis field is for validation purposes and should be left unchanged.
