Mom's CCAH Initial

Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.

Date

MM Client ID

Record ID

First Name

Session Number

Outcome

Number of Attempts

Phone call disposition

Do you have any physical health conditions that we should be aware of such as diabetes, high blood pressure, high cholesterol, kidney problems or dialysis, asthma, cancer, HIV or anything else that you've talked to your doctor about or have been told to follow a special diet?

If Yes, list health conditions/illnesses here:

Have you been diagnosed with a mental health condition, such as depression, anxiety, bipolar disorder, substance abuse disorder or addiction?

If Yes, list conditions here:

ATTENTION: If member does not have a physical or mental health condition, please choose unsure or n/a for remaining questions. Member is ineligible for participation.

In the past 6 months, have you been in the hospital, emergency room or a skilled nursing home?

If Yes/unsure, please list any additional information provided (or why they were hospitalized):

Has the amount of food you eat on a daily basis decreased, without wanting to, over the past 3 months?

Do you typically eat less than 2 meals per day?

If yes, why? (loss of appetite, access to healthy food options, digestive problems)

Do you typically eat less than 3 fruits and vegetables each day?

Do you have tooth or mouth problems that make it difficult to chew or swallow?

If yes, do you need pureed texture foods?

Without wanting to, have you had any weight change in the past 6 months?

If Yes, have you lost or gained weight?

Are you physically unable to, or is it challenging for you to shop, cook and/or feed yourself?

Do you have any food allergies or intolerances?

If Yes, note food allergies/intolerances here

Do you have access to a refrigerator to store meals?

If yes, do you have enough space (in either a refrigerator or freezer) to store 14 meals/week?

If no, do you need shelf stable meals?

Do you have a microwave or oven to heat the meals properly?

Does Member Have Any Contact/Demographic Info Changes (Address, Phone Number, Prefered Language, etc.)?

Member Contact Information Changes (if any):

Special Delivery Instructions (if any):

Please explain to member: “In addition to your nutrition calls, we will also send occasional texts with recipes, tips and other helpful info. If email is better for you, I can take an email address from you instead.” Member agreed to:

Email (or a different phone # for text):

Dietitian Summary:

Menu Recommendation:

Name of RD conducting this assessment

First NameLast Name

# of minutes on call

Community support line: 1-888-701-5279
Members can call in to adjust menu orders, change delivery day, put deliveries on hold, log a complaint, reship a cooler, etc.