Mom's Healthnet Initial Nutrition Screening Form

Mom's Healthnet Initial Nutrition Screening Form
Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.
Date*

MonthDayYear
Date
MM Client ID *
Record ID*
First Name*
Session Number
Outcome
Number of Attempts
Phone call disposition
Do you have any physical health conditions that we should be aware of such as diabetes, high blood pressure, high cholesterol, kidney problems or dialysis, asthma, cancer, HIV or anything else that you've talked to your doctor about or have been told to follow a special diet?*

YesNoUnsure
If Yes, list health conditions/illnesses here:
Have you been diagnosed with a mental health condition, such as depression, anxiety, bipolar disorder, substance abuse disorder or addiction?*

YesNoUnsure
If Yes, list conditions here:
ATTENTION: If member does not have a physical or mental health condition, please choose unsure or n/a for remaining questions. Member is ineligible for participation.
In the past 6 months, have you been in the hospital, emergency room or a skilled nursing home?*

YesNoUnsure
If Yes/unsure, please list any additional information provided (or why they were hospitalized):
Has the amount of food you eat on a daily basis decreased, without wanting to, over the past 3 months?*

YesNoUnsure
Do you typically eat less than 2 meals per day?*

YesNoUnsure
If yes, why? (loss of appetite, access to healthy food options, digestive problems)
Do you typically eat less than 3 fruits and vegetables each day?*

YesNoUnsure
Do you have tooth or mouth problems that make it difficult to chew or swallow?*

YesNoUnsure
If yes, do you need pureed texture foods?

YesNoN/A
Without wanting to, have you had any weight change in the past 6 months?*

YesNoUnsure
If Yes, have you lost or gained weight?

LostGainedn/a
Are you physically unable to, or is it challenging for you to shop, cook and/or feed yourself?*

YesNoUnsure
Do you have any food allergies or intolerances?*

YesNoUnsure
If Yes, note food allergies/intolerances here
Do you have access to a refrigerator to store meals?*

YesNoUnsure
If yes, do you have enough space (in either a refrigerator or freezer) to store 14 meals/week?

YesNoUnsure
If no, do you need shelf stable meals?

YesNoUnsure
Do you have a microwave or oven to heat the meals properly?*

YesNoUnsure
Does Member Have Any Contact/Demographic Info Changes (Address, Phone Number, Prefered Language, etc.)?*

YesNo
Member Contact Information Changes (if any):
Special Delivery Instructions (if any):
Dietitian Summary:*
Menu Recommendation:*

General WellnessHeart HealthyLower SodiumDiabetes FriendlyRenal FriendlyCancer SupportGluten FreeVegetarianPureedShelf StableN/A (not eligible, doesn't want, etc)
As part of your nutrition benefits you also have access to our VHPGO App. This is a nutrition resource developed by dietitians for extra support. There are recipes, nutrition and exercises classes, meal plans and you can even chat with a dietitian as needed. All I need is your email address to send you an invite." ****If they are interested, please let them know -- "You will receive an email with a link to register so be sure to check your inbox."
Email Address:*
Name of RD conducting this assessment
Name of RD conducting this assessment*

First NameLast Name
# of minutes on call*
Community support line: 1-888-701-5279
Members can call in to adjust menu orders, change delivery day, put deliveries on hold, log a complaint, reship a cooler, etc.
Should be Empty: