Meals on Wheels - NAPIS Form

Meals on Wheels - NAPIS Form

National Aging Program Information System (NAPIS) data is required by the federal government and is used by the South Dakota Adult Nutrition Program to track how many S0uth Dakotans receive meals. The data collected helps the Administration of Community Living determine how to allocate funding based on the aging population through the country. All collected information is kept confidential.
If you are under the age of 60, you must contact Dakota at Home for eligibility. You can either call them at 1-833-663-9673 or visit their online referral page to complete the process: Dakota at Home Referral Form.

Phone Numbers:*

Rows	List all applicable contact numbers.
Home Phone:
Cell Phone:
Other Phone:

Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Additional Phone
Format: (000) 000-0000.
Home Address:*
Please share reasons why the individual is in need of Meals on Wheels.
If approved for the Meals on Wheels program, please share any special delivery instructions:
Example: yellow home w/ blue shutters, knock and walk in, deliver to side door.
Preferred Hospital:
Primary Physician:

Nutrition Risk Assessment - mark yes/no based on what is true most days:*

Rows	Yes	No
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 2 meals per day?
Do you eat fewer than 5 servings (1/2 cup) of fruits or vegetables every day?
Do you eat fewer than 2 servings of dairy products (milk, yogurt, or cheese) everyday?
Do you have 3 or more drinks of beer, liquor, or wine almost every day?
Do you have trouble eating well due to problems with chewing/swallowing?
Do you sometimes not have enough money to buy the food you need?
Do you eat alone most of the time?
Do you take 3 or more different prescribed or over the counter drugs per day?
Without wanting to, have you lost or gained 10 pounds in the past 6 months?
At times, do you find it difficult to physically shop, cook, and/or feed yourself independently?

Does the participant need any special diet accommodations?

YesNo
Please check appropriate accommodations.

Ground up meatCut up meatNo fishNo PorkNo Chicken
Describe other problems that keep you from eating well:
If nothing, please put NA.
Describe any special dietary needs:
If nothing, please put NA.
If you are deemed a high-nutrition risk, our Registered Dietitian will need to be contacted.

Sara Berreth, MS, RDN, LN
605-695-8964; sara.berreth@state.sd.us

Activities for Daily Living - mark yes/no based on what is true most days:

Instrumental Activities of Daily Living - mark yes/no based on what is true most days:

Are you completing this form yourself or are you referring someone else?*

Completing myselfCompleting for someone else
Name of Referring Individual*

First NameLast Name
Relationship to the Client*
Phone of Referring Individual
Format: (000) 000-0000.
Should be Empty: