Mom's Gold Coast Nutrition Session 1 Form

Gold Coast Nutrition Session 1
Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.
MM Client ID *
Record ID*
Session # (from Column Z)*
Total Number of Sessions (from Column Y)*
Date*

MonthDayYear
Date
Outcome
Number of Attempts
Phone call disposition
YesNoUnsure
If Yes/unsure, please list any additional information provided (or why they were hospitalized):
YesNoUnsure
If Yes, list health conditions/illnesses here:
ATTENTION: If no, please discontinue session. Member is ineligible for participation.
YesNoUnsure
If yes, why? (loss of appetite, access to healthy food options, digestive problems)
YesNoUnsure
YesNoN/A
YesNoUnsure
LostGainedn/a
2-13 lbs14-23 lbs24-33 lbs34 lbs or moreUnsure
YesNoUnsure
Often trueSometimes trueNever true
Often trueSometimes trueNever true
Rate your overall health*
What is your confidence level in your ability to make healthy food choices?*
Summary: *
YesNo
If Member is declining meals, please explain why:
RD's Justification on Meal Extension:*
YesNo
Member Contact Information Changes (if any):
Additional (relevant) information provided by the client (if any):
Menu Recommendation:*
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: