Meals on Wheels Intake Form
Client Name
First Name
Last Name
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Client Phone Number
Please enter a valid phone number.
Alternate Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
Client Date of Birth
Client's Doctor's Name (Primary Care)
Client's Sex
Please Select
Male
Female
Other
Client Race
Please Select
African American/Black
Asian
Caucasian/White
Hispanic
Biracial
Other
Veteran
Please Select
Yes
No
Spouse of Veteran
Please Select
Yes
No
# of Persons in the Home
Emergnecy Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to client
Qualification Assessment
Why does the client need Meals on Wheels?
Does the individual shop for him/herself?
Yes
No
With assistance
If no, how is food currently obtained?
Does the individual drive?
Yes
No
Does the individual cook?
Yes
No
Describe the primary support (include name and relationship if not the emergency contact)
Is there family (note if involved/estranged/local/not local)?
How many meals does the individual eat daily?
3
2
1
0
If 2 or less, why?
Evidence of food insecurity?
Yes
No
Unsure
Are there any animals present in the home?
Does the individal have any of the following conditions (check all that apply)?
Diabetes
Stoke
Heart Disease
High Blood Pressure
COPD
Cancer
Dementia
Alzeihmer's
Mood Disorders (Bipolar, etc)
Does the individual use mobility assistance?
Walker
Wheelchair
Cane
Bedridden
Crutches
No mobility assistance
Does the individual have vision issues other than normal glasses?
Yes
No
If yes, please describe.
Does the individual have hearing issues
Yes
No
If yes, please describe.
Is there a caregiver/home health aid? If yes, how often?
Please describe any other health issues that affect mobility and ability to care for self.
Please list any dietary concerns or food allergies.
Please select the follwing kinds of protein the individual will eat:
Chicken
Beef
Pork
Fish
Please select the kinds of beverages the individual prefers
2% milk
Skim milk
Juice
No Drinks
Billing Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
If requesting financial assistance, please select your monthly income. Verification will be required to approve financial assistance.
$2,500+ per month
$1,800-$2,499 per month
$1,400-$1,799 per month
$1,000-$1,399 per month
$999 and under per month
Submit
Should be Empty: