A 31-year-old woman with severe intellectual disability (IQ 28) and limited verbal communication is brought to the PMHNP by her residential care staff for evaluation of new-onset screaming episodes, face-slapping, and refusal to eat that have escalated over the past ten days. Staff describe these behaviors as occurring primarily during mealtimes and personal care routines. She has a history of gastroesophageal reflux disease (GERD). Her current medications include omeprazole 20 mg daily and risperidone 0.5 mg twice daily. Physical examination reveals a red, swollen area on her right lower jaw. Her most recent dental examination was over 18 months ago. The PMHNP integrates this information into the assessment. Which of the following represents the most appropriate initial assessment strategy?