ENG: Nurture & Nourish for the Future

Nurture & Nourish for the Future
Full Name*

First NameLast Name
Contact Number*
Email Address
What is your Zipcode?*
Has a doctor or nurse ever told you that you have any of the following? (Check all that apply)*

High blood pressureDiabetes (Type 1 or 2)I haven’t been told by a doctor, but I think I might have high blood pressure or diabetesNone of the above
In the past year, were you ever worried that your food would run out before you had money to buy more?*

YesSometimesNo
In the past year, did the food you bought run out, and you didn’t have money to get more?*

YesSometimesNo
Program Activities

Here’s what you’ll be asked to do if you join:
- Share basic health info (like blood pressure or blood sugar numbers)
- Fill out short health and food surveys
- Participate in one-on-one nutrition coaching or join at least one nutrition class
- Stay in touch with our team from time to time
- Commit to the program for at least 6 months
Here’s what you’ll get:
- Free groceries for you and your household every 2 weeks through our E-Pantry
- Nutrition tips and education
- Help managing high blood pressure or diabetes
- A team that cares about your health and well-being
If you qualify, are you willing to take part in these activities?*

YesMaybe, I have questionsNo
Do you have any questions or anything else you’d like to share?
This website is supported by Texas Health Resources as part of a Texas Health Community Impact grant award. The contents are those of the author(s) and do not necessarily represent the official views of Texas Health.
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