Umoja Contra Costa Initial Assessment

Contra Costa Initial Assessment
ID *
Name*

First NameLast Name
DOB*

MonthDayYear
Birthdate
Medical History
Height*
Weight*
BMI*
Check all health condition(s) that apply to this client:*

ObesityDiabetesChronic kidney diseaseHeart disease (HTN, hyperlipidemia, MI, stroke, CHF, etc.)Pulmonary disease (COPD, cystic fibrosis, etc.)HIVCancerMental health illness (anxiety, depression, bipolar disorder, etc.)Substance abuse disorder or addictionOther
Medications: *
Has client been discharged from the hospital or a skilled nursing facility within the last 6 months?*

YesNo
If yes, please list any additional information provided:
Food Security & Nutritional Status
Without wanting to, have you had any weight change in the last 6 months?*

YesNo
If yes, have you lost or gained weight?

LostGained
Please list any additional information provided:
Has the amount of food you eat on a daily basis decreased, without wanting to, over the past 3 months?*

YesNo
If yes, why?
Do you typically eat less than 2 meals per day?*

YesNo
If yes, why?
Do you typically eat less than 3 fruits and vegetables per day?*

YesNo
If yes, why?
Are you physically unable to, or is it challenging for you to shop, cook, and/or feed yourself?*

YesNo
If yes, why?
24 hr diet recall:*
Food Allergies

MilkEggsFishShellfishPeanutsTree nutsWheatSoybeansSesameOther
Disclaimer: We make every attempt to avoid all major allergens in our Medically Tailored Grocery boxes, but we cannot guarantee that boxes are allergen-free. It is the member’s responsibility to read all labels.
Food intolerances:

Milk/lactose intoleranceGluten intoleranceOther
Dietitian Summary (justification for medically tailored grocery benefit): *
Medically tailored grocery selection:*

MTG Box 1 - Diabetic/Cardiovascular DisorderMTG Box 2 - CKD Friendly
RD Name*
# of mins on call*
Should be Empty:

Contra Costa Initial Assessment

Medical History

Food Security & Nutritional Status