Provider
Grant Name
Site
First Name
Last Name
Gender
Marital Status
Primary Language
English Proficiency
Date of Birth (MM/DD/YYYY)
Phone
Street
City
State/Province
Zip
Has Alzheimer’s Disease or a Related Dementia
Ethnicity
Race (select all that apply)
Their Individual Income is About:
They Live With Their Spouse and Both of Their Income Is About:
Living Arrangements
Housing
Meal Eligibility Type
They Need Help With the Following Activities (select all that apply)
They Need Help With the Following Activities (select all that apply)
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?
In the Last 12 Months If the Individual Had Groceries, Did They Have Support With Meal Prep?
If No For Above 2 Questions, When Did They Experience This?
In the Last 12 Months Have They Skipped Meals Due to Financial Hardship?
In the Last 12 Months Have They Ate Less Food Then Needed Due to Financial Hardship?
In the Last 12 Months Were They Ever Hungry Due to Financial Hardship?
If Yes For Above 3 Questions, When Did They Experience This?
Have They Lost Weight Without Trying?
If Yes For Above Question, How Much Weight?
Have They Had Decreased Appetite?
Have They Been Hospitalized In the Last 12 Months?
If Yes For Above Question, When Were They Last Hospitalized?
Provider & Grant Name
Additional Comments

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