HDM Registration Form

Home Delivered Meals Registration

Must be at least 60 years old and a resident of Jefferson County.
Applicant Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Race / Nationality*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your annual income?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Applicant*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Nutrition
YesNo
Do you have any food allergies?*
Skim Milk2% MilkWhole MilkJuiceNone
List any allergies that you may have.
WhiteWheatNone
ADL & IADL's

Activities of Daily Living & Instrumental Activities of Daily Living
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur
IndependentNeed SupervisionMinimal AssistanceMostly DependentTotally DependentActivity does not occur

Nutritional Risk Form*

Rows	Yes	No
Have you made any eating habit changes due to health reasons?
Do you eat fewer than (2) meals per day?
Do you eat fewer than (5) servings (1/2 cup each) of fruit or vegetables everyday?
Do you eat fewer than (2) servings of dairy products (Milk, Yogurt, Cheese) everyday?
Do you sometimes not have enough money to buy food?
Do you have any trouble eating well due to problems chewing or swallowing?
Do you eat alone most of the time?
Without wanting to have you lost or gained (10) pounds in the last (6) months?
Are you not always physically able to shop, cook, and/or feed yourself (or to get someone to do it for you?
Do you have (3) or more drinks of beer, liquor, or wine almost everyday?
Do you take (3) or more prescription or over the counter drugs per day?

Should be Empty:

Home Delivered Meals Registration

Emergency Contact Information

Nutrition

ADL & IADL's