Nutritional Screen
1. Do you have a illness or condition that changes the kind and or food you can eat?
Yes
No
2. Do you eat fewer then two meals a day?
Yes
No
3. Do you eat few fruits and Vegetables?
Yes
No
4. Do you eat/drink few dairy products?
Yes
No
5. Do you have a tooth or mouth problem that make it hard for you to eat?
Yes
No
6. Do you normally have enough money throughout the month to buy food?
Yes
No
7. Do you eat alone most of the time?
Yes
No
8. Do you take 3 or more prescription or over the Counter Medications?
Yes
No
9. Without wanting to have you lost or gained 10 pounds in the last 6 months?
Yes
No
Height
Weight
10. Are you always able to shop ,cook, and or feed yourself?
Yes
No
11. Do you drink 3 or more glasses of beer, liquor, or wine almost every day?
Yes
No
12. Do you feel meal service will benefit you?
Yes
No
Your Phone Number
Submit
Should be Empty: