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Older Adult Demographic Information
Name of Site:
Registration for Congregate Meals
Street Address Line 2
State / Province
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Hispanic or Latino
Not Hispanic or Latino
Black or African American
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Asian or Asian American
Limited English Speaking:
If yes, specify language:
Lives with Others
Number of individuals living in Household
Major Health Problems (check all that apply)
Nutrition Risk Screen( check points under Yes or NO, then total column)
I have an illness or condition that made me change the kind and/or amount of food I eat.
I eat fewer than 2 meals per day.
I eat few fruits and vegetables, or milk products.
I have three or more drinks of beer, liquor, or wine almost every day.
I don't always have enough money to buy the food I need.
I eat alone most of the time/
I take three or more different prescribed or over-the- counter drugs a day.
Without wanting to, I have lost or gained 10 pounds in the last six months.
I am not always physically able to shop, cook, and/ or feed myself.
I have tooth or mouth problems that make it hard for me to eat.
Six or more points= High Nutritional risk
Column Totals: /21 possible points
Additional Nutrition Information
Nutritional Risk was explained to client.
Client is considered at High Nutritional Risk. A recommendation was made to follow up with healthcare provider.
Does client have difficulty swallowing:
Client food source for the weekends:
NOTE: it is the client's responsibility to review the weekly menu and bring any allergy concerns to the attention of the nutrition provider. When feasible, the provider will supply a special meal to meet the dietary needs of the client.
The client was informed of the possibility that foods may contain or come into contact with food allergens.
Other Contact Information
Emergency Contact Name #1:
Emergency Contact Name #2:
Authorization of Release of Information
I give permission to the provider and/or the Area Agency on Aging Staff to discuss my needs.
Staff Person Initials:
IL 402-1264 (06/21)
Should be Empty: