Provider |
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Grant Name |
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Assessment Status |
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Site |
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First Name |
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Last Name |
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Gender |
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Marital Status |
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Primary Language |
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English Proficiency |
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Date of Birth (MM/DD/YYYY) |
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Phone (###-###-####) |
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Mobile Phone |
|
|
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Street |
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City |
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State/Province |
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Zip |
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Has Alzheimer’s Disease or a Related Dementia |
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Is Disabled and Under 60: |
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Ethnicity |
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Race |
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Their Individual Income is About: |
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They Live With Their Spouse and Both of Their Income Is About: |
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Living Arrangements |
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Housing |
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Meal Eligibility Type |
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They Need Help With the Following Activities (select all that apply) |
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They Need Help With the Following Activities (select all that apply) |
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Diet |
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Number of Days |
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Emergency Contact Information |
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Has Illness/Condition That Changed Eating Habits(2) |
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Eats Fewer Than 2 Meals A Day(3) |
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Eats Few Fruits and Vegetables or Milk Products(2) |
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Has Problem Chewing/Swallowing(2) |
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Doesn't Have Enough Money/Food Stamps To Buy Food(4) |
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Takes 3+ Medication(1) |
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Eats Alone Most of the Time(1) |
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Has 3+ Alcoholic Drinks A Day(2) |
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Without Wanting to, Has Weight Change of 10 Pounds(2) |
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Not Able to Shop/Cook/Eat independently(2) |
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