Food For Health Program
Must be 18 to 54 years of age
*INTAKE & CONSENT FORM
Name
*
First Name
Last Name
Address
*
Address
Street Address Line 2
City
State
Zip
Home Phone Number
Please enter a valid phone number.
Contact Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Hispanic?
yes
No
Race / Ethnicity
*
Black or African American
Hispanic
White or Caucasian
American Indian or Alaskan Native
Asian
Native Hawaiian or Pacific Islander
Prefer not to answer
Two or more racial backgrounds
Race
Primary Language
*
Other Languages
Highest Grade Completed
*
Currently Employed
*
Yes
No
Military Status
*
None
Active
Veteran
Other
Military Status
If, yes where?
How many months have you worked in the last 12 months?
*
Your income after-taxes in the last 12 months?
*
Marital Status
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Children?
*
Yes
No
If So, Please List Their Ages
Criminal Convictions
*
How Many in Household
*
Past 12 Months, Gross Household Income
*
Living Arrangement:
*
Own
Rent
Apartment
Subsidized
Unsubsidized
Homeless
Stay For Free
Health Insurance Status
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None
Government Program
Through Employer
Insured Through Family
Do you have the following health conditions?
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None
Diabetes
High Cholesterol
Hypertension
Obesity
Pre-Diabetic
SECTION 2
In the last 12 weeks, have you or anyone in your household received EBT, food stamps or SNAP benefits?
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Yes
No
How long have you been receiving EBT, food stamps, or SNAP benefits?
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I just started
Less than a year
More than a year
In the last 12 weeks, how often did you eat FRUIT like apples, bananas, oranges, melon or any other fruit? INCLUDE fresh, frozen, canned, or dried fruit. DO NOT INCLUDE JUICES.
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Never
1 time a week
2 times a week
3-4 times a week
5-6 times a week
1 time per day
2-3 times per day
4-5 times per day
6 or more times per day
In the last 12 weeks, how often did you eat GREEN LEAFY or LETTUCE SALAD with or without other vegetables?
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Never
1 time a week
2 times a week
3-4 times a week
5-6 times a week
1 time per day
2-3 times per day
4-5 times per day
6 or more times per day
In the last 12 weeks, how often did you eat other VEGETABLES like broccoli, collard greens, corn, carrots, green beans, potatoes? ALSO INCLUDE vegetables that are raw, boiled, steamed, baked, stewed, grilled, stir-fried, or microwaved. DO NOT INCLUDE FRIED VEGETABLES
*
Never
1 time a week
2 times a week
3-4 times a week
5-6 times a week
1 time per day
2-3 times per day
4-5 times per day
6 or more times per day
In the last 12 weeks, how often did you eat any kind of fried vegetables like french fries, hash browns, onion rings, potato chips, deep fried mushrooms, or any other deep fried vegetable?
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Never
1 time a week
2 times a week
3-4 times a week
5-6 times a week
1 time per day
2-3 times per day
4-5 times per day
6 or more times per day
In the last 12 weeks, how often did you eat fried foods or fast foods?
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Never
1 time a week
2 times a week
3-4 times a week
5-6 times a week
1 time per day
2-3 times per day
4-5 times per day
6 or more times per day
In a typical week during the last 12 weeks, how often do you participate in an aerobic activity or an activity that increased your heart rate and breathing, like a brisk walk or jogging, chair aerobics, dancing, biking, swimming, yard work or gardening?
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Never
1 time per week
2 times per week
3-4 times per week
5-6 times per week
Unable to
How many TOTAL HOURS a week do you usually do aerobic activities?
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Less than 1 hour
1-2 hours
3-4 hours
5-6 hours
7 or more hours
In a typical week during the last 12 weeks, how often did you participate in strength building activities like lifting free weights, using resistance bands, and using resistance machines at the gym?
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Never
1 time per week
2 times per week
3-4 times per week
5-6 times per week
Unable to
How many TOTAL HOURS a week do you usually do strength building activities?
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Less than 1 hour
1-2 hours
3-4 hours
5-6 hours
7 or more hours
In a typical week during the last 12 weeks, how often did you participate in flexibility and balance activities like stretching exercises, Yoga, and Tai Chi?
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Never
1 time per week
2 times per week
3-4 times per week
5-6 times per week
Unable to
How many TOTAL HOURS a week do you usually do flexibility and balance activities?
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Less than 1 hour
1-2 hours
3-4 hours
5-6 hours
7 or more hours
In the last 12 weeks, did you participate in any nutrition or food education activities, like cooking classes, a consultation with a dietician, or "healthy eating on a budget" classes?
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No, I did not participate in any activities
Yes, I participated in 1 activity
Yes, I participated in 2 or more activities
The food that we bought just didn't last, and we didn't have the money to get more. Was this often, sometimes, or never true for your household in the last 12 weeks, that is, the past 90 days.
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Often True
Sometimes True
Never True
Don't Know
We couldn't afford to eat balanced meals. Was this often, sometimes, or never true for your household in the last 12 weeks?
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Often True
Sometimes True
Never True
Don't Know
In the last 12 weeks, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money or food?
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Yes
No
Don't Know
If Yes, how many days did this happen?
In the last 12 weeks, did you ever eat less than you felt you should because there wasn't enough money or food?
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Yes
No
Don't Know
In the last 12 weeks, were you ever hungry, but didn't eat because there wasn't enough money or food?
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Yes
No
Don't Know
Would you say in general, how would you rate your health?
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Poor
Fair
Good
Very Good
Excellent
Now thinking about your physical health, which includes physical illness and injury, how many days during the past 90 days was your physical health not good?
*
Now, thinking about your mental health, which includes stress, depression, and problems with emotions, how many days in the past 90 days was your mental health not good?
*
During the past 90 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?
*
Today's Date
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Month
/
Day
Year
Date
Signature
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