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Provider
Grant Name
Site
First Name
Last Name
Company
Email
Collected Date
ADLs
IADLs
Gender
Marital Status
Ethnicity
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Single Income
Combined Income
Living Arrangements
Housing
Street
City
State/Province
Zip
Weight Change
Dairy Serving
Meal Count
3+ Alcoholic Drinks
3+ Medications
Eats Alone
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Produce Servings
Alzheimers/Dementia
Cognitive Impairment Notes
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