• Meals on Wheels Application

    Meals on Wheels Application

  • Applicant Information

  • Pronouns
  • Birthdate
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 0/255

  • Emergency Contact

  • Format: (000) 000-0000.

  • Contact Instructions

  • Call?
  • Do you need interpreter services?
  • Format: (000) 000-0000.
  • 0/32768

  • Reason for needing Meals on Wheels

  • Select one:

  • *To be eligible for services, an individual needs to meet the following criteria: Age 60 or older, homebound, unable to prepare meals, difficulty performing activities like bathing, dressing or shopping, and does not have an informal support system.*

  • Health Information

  • Medical conditions (please check all that apply)
  • 0/255

  • Disabilities

  • Disabilities (Check all that apply)
  • 0/100

  • Nutrition Information

  • Do you have an illness or condition that made you change the kind and/or amount of food you eat?
  • Do you eat fewer than two meals per day?
  • Do you eat few fruits or vegetables or milk products?
  • Do you have three or more drinks of beer, liquor, or wine almost every day?
  • Do you have tooth or mouth problems that make it hard for you to eat?
  • Do you sometimes not have enough money to buy the food you need?
  • Do you eat alone most of the time?
  • Do you take three or more different prescribed or over-the-counter drugs a day?
  • Have you lost or gained ten pounds in the last six months without trying?
  • Is it physically difficult for you to shop, cook, and/or feed yourself at times?

  • Activities of Daily Living

  • What level of assistance do you need with the following?

  • Eating
  • Walking/Ambulating
  • Using the Telephone
  • Dressing
  • Preparing Meals
  • Heavy Housework
  • Bathing
  • Shopping
  • Transportation
  • Toileting
  • Managing Medications
  • Transferring out of bed/chair
  • Managing Money
  • Chores
  • Is there anyone in your life who usually helps you out?
  • Do you use an assistance device like a cane, walker, or wheelchair?

  • Applicant Demographic Information

  • Gender
  • Race (select all that apply)
  • Sexual Orientation
  • Approx. Annual Income (1 person household)
  • Approx. Annual Income (2 person household)
  • Approx. Annual Income (3 person household)
  • Approx. Annual Income (4 person household)
  • Which ONE of the following best describes your living situation?
  • Does your household have children under the age of eighteen?
  • Are you a veteran of the U.S. Military?
  • Is your spouse a veteran of the U.S. Military?
  • Are you homeless or living in temporary housing?
  • Should be Empty: