Congregate Form- English

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
This form must be completed by the appropriate Congregate nutrition provider.
Date:

Month Day Year
Date
Name:
DOB:
Address

Address

Street Address Line 2

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)
Should be Empty:

Older Adult Demographic Information