Provider
Grant Name
Assessment Status
Site
First Name
Last Name
Gender
Marital Status
Primary Language
English Proficiency
Date of Birth (MM/DD/YYYY)
Phone (###-###-####)
Mobile Phone
Street
City
State/Province
Zip
Has Alzheimer’s Disease or a Related Dementia
Is Disabled and Under 60:
Ethnicity
Race
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(2)
Eats Fewer Than 2 Meals A Day(3)
Eats Few Fruits and Vegetables or Milk Products(2)
Has Problem Chewing/Swallowing(2)
Doesn't Have Enough Money/Food Stamps To Buy Food(4)
Takes 3+ Medication(1)
Eats Alone Most of the Time(1)
Has 3+ Alcoholic Drinks A Day(2)
Without Wanting to, Has Weight Change of 10 Pounds(2)
Not Able to Shop/Cook/Eat independently(2)
Provider & Grant Name
Additional Comments

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