GA Foods Assessment

GA Foods Assessment
Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.
GA Client ID *
Phone Number*
Date*

YearMonthDay
Date
Name*

First NameLast Name
DOB*

YearMonthDay
Birthdate
Healthplan*
Type of Appointment*
Reason for declining
Weight*
Height*
BMI*
Classify*
Do you have any chronic physical health conditions such as diabetes, high blood pressure, high cholesterol, kidney disease, liver disease, or cancer?*

YesNo
Physical health condition(s)
If member has renal disease, please document dialysis
If member is diabetic, please document HgbA1C
If member is diabetic please document blood sugar range
If member has high blood pressure, please document latest BP measurement
Have you been diagnosed with a mental health condition such as: depression, anxiety, bipolar disorder, substance abuse, or other?*

DepressionAnxietySchyzophreniaBipolarSubstance abuseN/AOther
Have you recently been in the hospital, emergency room or a skilled nursing home?*

YesNoMember is at high risk for hospitalization and/or has extensive care coordination needs
Are you on a prescribed diet?*
How would you rate your overall health?*
What is your confidence in your ability to manage your health conditions?*
Do you typically eat less than 2 meals per day*
How many sweetened beverages do you drink per day? (juice, sodas, power drinks, coffees/lattes, etc)*
How many servings of fruits and vegetables do you eat per day?*
Do you have chewing or swallowing difficulty?*
Do you have unintentional gain or loss of over 10lbs in last 6 months?*
Do you have any food allergies or intolerances? *Dietitian MUST at this time explain that these questions are for documenting purposes, and that GA Foods is unable to provide allergen free meals at this time.*
Do you have a freezer to store meals we will be sending you?*
Do you have an oven and or microwave?*
Summary Note from Dietitian*
Describe nutrition education provided*
Before submitting assessment, please ensure a diet order has been selected.
Diet order: CalAim
Diet order: Aetna KY
Oral Nutrition Supplement Recommendation

Ensure Plus, 8 fl ozEnsure High Protein, 8 fl ozGlucerna, 8 fl ozNepro, 8 fl ozEnsure Surgery, 8 fl ozJuven, 8 fl oz preparedPulmocare, 8 fl ozSuplena, 8 fl oz
Additional consultations recommended? (Add # recommended per plan)*
Member contact information changes:*
If this is the final appointment, is there a recommendation for an extension of benefits?*
If yes, extension of meal benefits and nutritional counseling recommended due to continued need to support treatment of (list member’s current health conditions)
"As part of your nutrition benefits you also have access to our VHPGO App. This is a nutrition resource developed by dietitians for extra support. There are recipes, nutrition and exercises classes, meal plans and you can even chat with a dietitian as needed. All I need is your email address to send you an invite." ****If they are interested, please let them know -- "You will receive an email with a link to register so be sure to check your inbox."
Email Address*
RD Name*
Number of minutes on call*
GA Customer Care Phone: 1-866-575-2772
GA Customer Care E-mail: carecenter@gafoods.com
Before submitting assessment, please ensure a diet order has been selected.
Should be Empty: