Provider*	--None-- CC Elderly Nutrition RW Solutions
Grant Name*	Select Grant CC Elderly Nutrition RW Elderly Nutrition
Site*
First Name*
Last Name*
Gender*	--None-- Female Male Non-Binary Other
Marital Status*	--None-- Married Widowed Divorced Separated Single
Primary Language*	--None-- English Spanish Italian Polish French Chinese Creole Russian German Greek Hindi Vietnamese Urdu Albanian Korean Arabic Gujarathi Kru, Ibo, Yoruba Telegu Serbo-Croatian Bengali Ukrainian Japanese Mandarin Hungarian Tamil Turkish Patois American Sign Language Other Danish Cantonese Romanian Farsi Cambodian Portuguese Tactical Sign Language
English Proficiency*	--None-- Proficient English Some English Limited English No English
Date of Birth (MM/DD/YYYY) *
Phone (###-###-####)*
Street*
City*
State/Province*
Zip*
Has Alzheimer’s Disease or a Related Dementia
Ethnicity*	--None-- Hispanic/Latino Not Hispanic/Latino
Race (select all that apply)*	White Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander
Their Individual Income is About:	--None-- Under $1,215 (100%) $1,216 - $1,519 (125%) $1,520 - $1,823 (150%) $1,824 - $2,126 (175%) $2,127 - $2,430 (200%) $2,431 or over (over 200%)
They Live With Their Spouse and Both of Their Income Is About:	--None-- Under $1,643 (100%) $1,644 - $2,054 (125%) $2,055 - $2,465 (150%) $2,466 - $2,876 (175%) $2,877 - $3,287 (200%) $3,288 or over (over 200%)
Living Arrangements*	--None-- Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others
Housing*	--None-- Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other
Meal Eligibility Type*	--None-- Age 60 or 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*	--None-- Yes No
Eats Fewer Than 2 Meals A Day*	--None-- Yes No
Eats Few Fruits and Vegetables or Milk Products*	--None-- Yes No
Has Problem Chewing/Swallowing*	--None-- Yes No
Doesn't Have Enough Money/Food Stamps To Buy Food*	--None-- Yes No
Takes 3+ Medications*	--None-- Yes No
Eats Alone Most of the Time*	--None-- Yes No
Has 3+ Alcoholic Drinks A Day*	--None-- Yes No
Without Wanting to, Has Weight Change of 10 Pounds*	--None-- Yes No
Not Able to Shop/Cook/Eat independently*	--None-- Yes No
Have They Been Hospitalized In the Last 12 Months? *	--None-- Yes No

Provider & Grant Name*
Additional Comments