Food For Health Program

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 *

None Government Program Through Employer Insured Through Family
Do you have the following health conditions? *

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? *

Yes No
How long have you been receiving EBT, food stamps, or SNAP benefits? *

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. *

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? *

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? *

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? *

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? *

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? *

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? *

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? *

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? *

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? *

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? *

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. *

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? *

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? *

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? *

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? *

Yes No Don't Know
Would you say in general, how would you rate your health? *

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 *

Month Day Year
Date
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