Provider*	Please pick one CC Elderly Nutrition Program Stamford Senior Center RW Solutions
Grant Name*	Select Grant CC Elderly Nutrition Program Stamford Senior Center Congregate Meals RW Elderly Nutrition
Assessment Status*	Please pick one New Reassessment
Site*
First Name*
Last Name*
Gender*	Please pick one Female Male Non-Binary Other
Marital Status*	Please pick one Married Widowed Divorced Separated Never Married
Primary Language*	Please pick one Arabic American Sign Language Albanian Bengali Cambodian Cantonese Chinese Haitian/Creole Danish English Farsi French German Gujarathi Greek Hindi Italian Japanese Korean Kru, Ibo, Yoruba Mandarin Hungarian Patois Romanian Serbo-Croatian Tamil Telegu Portuguese Polish Russian Spanish Tactical Sign Language Turkish Ukrainian Urdu Vietnamese Other
English Proficiency*	Please pick one Very Well Well Not well Not At All
Date of Birth (MM/DD/YYYY) *
Phone (###-###-####)*
Mobile Phone
Email
Street*
City*
State/Province*
Zip*
Has Alzheimer’s Disease or a Related Dementia	Please pick oneNone Early Onset Dementia Mild Moderate Severe unknown /select>
Is Disabled and Under 60:
Ethnicity*	Please pick one Hispanic/Latino Not Hispanic/Latino
Race *	Please pick one White Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander Other
Their Individual Income is About:	Please pick one Under $1,255 (100%) $1,256 - $1,569 (125%) $1,570 - $1,883 (150%) $1,884 - $2,196 (175%) $2,197 - $2,510 (200%) $2,511 or over (over 200%)
They Live With Their Spouse and Both of Their Income Is About:	Please pick one Under $1,703 (100%) $1,704 - $2,129 (125%) $2,130 - $2,555 (150%) $2,556 - $2,981 (175%) $2,982 - $3,407 (200%) $3,408 or over (over 200%)
Living Arrangements*	Please pick one Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others
Housing*	Please pick one Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other
Meal Eligibility Type*	Please pick one Age 60 or Older Caregiver Age 60 and 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(2)*	Please pick one Yes No
Eats Fewer Than 2 Meals A Day(3)*	Please pick one Yes No
Eats Few Fruits and Vegetables or Milk Products(2)*	Please pick one Yes No
Has Problem Chewing/Swallowing(2)*	Please pick one Yes No
Doesn't Have Enough Money/Food Stamps To Buy Food(4)*	Please pick one Yes No
Takes 3+ Medication(1)*	Please pick one Yes No
Eats Alone Most of the Time(1)*	Please pick one Yes No
Has 3+ Alcoholic Drinks A Day(2)*	Please pick one Yes No
Without Wanting to, Has Weight Change of 10 Pounds(2)*	Please pick one Yes No
Not Able to Shop/Cook/Eat independently(2)*	Please pick one Yes No

Provider & Grant Name*
Additional Comments