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Name
*
First Name
Last Name
I have read and understand the information above.
*
Clear
Date
-
Month
-
Day
Year
Date
Older Adult Demographic Information
Name of Site:
Registration for Congregate Meals
New Client
Renewal
Date:
/
Month
/
Day
Year
Date
Name:
*
DOB:
*
Address
*
Address
Street Address Line 2
City
State / Province
Zip Code
Email:
*
example@example.com
Phone:
Cell Phone:
*
* will be used to call and text you information about important updates, closures and changes to programming.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
White
Black or African American
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Asian or Asian American
Marital Status:
Married
Divorced
Single
Widowed
Legally Separated
Domestic Partner
Gender
Male
Female
Other
Limited English Speaking:
Yes
No
If yes, specify language:
Monthly Income:
Below Poverty
Yes
No
Lives Alone
Lives with Others
Number of individuals living in Household
Major Health Problems (check all that apply)
Ambulation
Hearing
Vision
Other:
Nutrition Risk Screen( check points under Yes or NO, then total column)
Yes
NO-0
I have an illness or condition that made me change the kind and/or amount of food I eat.
Y-2
I eat fewer than 2 meals per day.
Y-3
I eat few fruits and vegetables, or milk products.
Y-2
I have three or more drinks of beer, liquor, or wine almost every day.
Y-2
I don't always have enough money to buy the food I need.
Y-4
I eat alone most of the time/
Y-1
I take three or more different prescribed or over-the- counter drugs a day.
Y-1
Without wanting to, I have lost or gained 10 pounds in the last six months.
Y-2
I am not always physically able to shop, cook, and/ or feed myself.
Y-2
I have tooth or mouth problems that make it hard for me to eat.
Y- 2
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.
Special Diet
General
Diabetic
Other:
Does client have difficulty swallowing:
Yes
No
Client food source for the weekends:
Dietary restrictions:
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:
*
Daytime/Cell Phone:
*
Emergency Contact Name #2:
Daytime/Cell Phone:
Authorization of Release of Information
I give permission to the provider and/or the Area Agency on Aging Staff to discuss my needs.
Signature
*
Clear
Date:
/
Month
/
Day
Year
Date
Staff Person Initials:
IL 402-1264 (06/21)
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