Provider* --None-- CC Elderly Nutrition CW Resources Inc Grant Name* Select Grant CC Elderly Nutrition CW Elderly Nutrition Site* First Name* Last Name* Gender* --None-- Female Male Non-Binary Other Marital Status* --None-- Married Widowed Divorced Separated Single Primary Language* --None-- English Spanish Italian Polish French Chinese Creole Russian German Greek Hindi Vietnamese Urdu Albanian Korean Arabic Gujarati Kru, Ibo, Yoruba Telegu Serbo-Croatian Bengali Ukrainian Japanese Mandarin Hungarian Tamil Turkish Patois American Sign Language Other Danish Cantonese Romanian Farsi Cambodian Portuguese Tactical Sign Language English Proficiency* --None-- Proficient English Some English Limited English No English Date of Birth (MM/DD/YYYY) * Phone* Street* City* State/Province* Zip* Has Alzheimer’s Disease or a Related Dementia Ethnicity* --None-- Hispanic/Latino Not Hispanic/Latino Race (select all that apply)* --None-- White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Their Individual Income is About: --None-- Under $1073 (100%) $1074-$1342 (125%) $1343-$1610 (150%) $1611-$1878 (175%) $1879-$2147 (200%) $2148 or over (over 200%) They Live With Their Spouse and Both of Their Income Is About: --None-- Under $1452 (100%)) $1453-$1815 (125%) $1816-$2178 (150%) $2179-$2540 (175%)) $2541-$2903 (200%) $2904 or over (over 200%) Living Arrangements* --None-- Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others Housing* --None-- Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other Meal Eligibility Type* --None-- Age 60 or Older Disabled in Elderly Housing Disabled Living With Elderly Person Spouse of Person Age 60 or Older Volunteer They Need Help With the Following Activities (select all that apply) --None-- Eating Dressing Bathing/Washing Using Toilet Getting Out of Bed/Chair Continence They Need Help With the Following Activities (select all that apply) --None-- Planning/Preparing Meals Shopping Managing Money Using Telephone Housekeeping Doing Laundry Taking Medicine Using Transportation Diet* Number of Days* Emergency Contact Information* Nutritional Risk- Select All that Apply Has Illness/Condition That Changed Eating Habits Eats Fewer Than 2 Meals A Day Eats Few Fruits and Vegetables or Milk Products Has Problem Chewing/Swallowing Doesn't Have Enough Money/Food Stamps To Buy Food Takes 3+ Medications Eats Alone Most of the Time Has 3+ Alcoholic Drinks A Day Without Wanting to, Has Weight Change of 10 Pounds Not Able to Shop/Cook/Eat independently In the last 12 months If the Individual Had Groceries, Could They Prepare A Meal? * Yes No In the Last 12 Months If the Individual Had Groceries, Did They Have Support With Meal Prep? * --None-- Yes No If No For Above 2 Questions, When Did They Experience This? --None-- 1-3 Months 4-6 Months 7+ Months In the Last 12 Months Have They Skipped Meals Due to Financial Hardship? * --None-- Yes No In the Last 12 Months Have They Ate Less Food Then Needed Due to Financial Hardship? * --None-- Yes No In the Last 12 Months Were They Ever Hungry Due to Financial Hardship? * --None-- Yes No If Yes For Above 3 Questions, When Did They Experience This? --None-- 1-3 Months 4-6 Months 7+ Months Have They Lost Weight Without Trying? * --None-- Yes No If Yes For Above Question, How Much Weight? --None-- 1-13 lbs 14-23 lbs 24-33 lbs 34 + lbs Unsure Have They Had Decreased Appetite? * --None-- Yes No Have They Been Hospitalized In the Last 12 Months? * --None-- Yes No If Yes For Above Question, When Were They Last Hospitalized? --None-- 1-3 Months 4-6 Months 7+ Months Provider & Grant Name* Additional Comments
