• Gold Coast Nutrition Session 1

  • Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.

  • Date*
     - -
  • In the past 6 months, have you been in the hospital, emergency room or a skilled nursing home?*
  • 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?*

  • ATTENTION: If no, please discontinue session. Member is ineligible for participation.

  • Has the amount of food you eat on a daily basis decreased, without wanting to, over the past 3 months?*
  • Do you have tooth or mouth problems that make it difficult to chew or swallow?*
  • If yes, do you need pureed texture foods?
  • Without wanting to, have you had any weight change in the past 6 months?*
  • If Yes, have you lost or gained weight?
  • If Yes, about how much weight have you lost/gained?
  • Are you physically unable to, or is it challenging for you to shop, cook and/or feed yourself?*
  • Within the past 12 months, have you been worried whether your food wound run out before you have money to buy more?*
  • Within the past 12 months, the food you bought didn’t last and you didn’t have money to get more?*
  • Member can benefit from an extension of meal authorization as there continues to be a medical necessity for ongoing nutrition support*
  • Does Member Have Any Contact/Demographic Info Changes (Address, Phone Number, Preferred Language, etc.)?*

  • 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: