Q1-5: Physical Assessments

*NOTE: If completing this form for the 100-day reporting period, “date of last report” should be interpreted as “day 0 (i.e., infusion).”

Question 1: Date of evaluation

Report the date of the most recent physical evaluation where both the abdominal girth and blood pressure were assessed in the reporting period. This evaluation will be used to answer questions 2 – 5 below.

Questions 2 – 3: Abdominal girth

Indicate if the recipient’s abdominal girth was measured on the date of evaluation specified in question 1. If Known, specify the recipient’s abdominal measurement in centimeters. If the recipient’s abdominal girth was not measured or if no information is available, select Unknown and go to question 4.

Questions 4 – 5: Blood pressure (BP)

Indicate if the recipient’s blood pressure was assessed on the date of evaluation specified in question 1. If assessed, report Known and provide the recipient’s blood pressure. If the recipient’s blood pressure was not measured or if no information is available to determine if the recipient’s blood pressure was measured, select Unknown and go to question 6.

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)
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