REFERRAL

Nutrition Client Intake Form

In order to meet state requirements this form must be completed upon your first visit to a meal site. Upon completing this form, you will need to call your meal site to reserve a meal. This form DOES NOT reserve your meal.

Step 1 of 2

50%

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Is the address listed above your mailing address?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Phone*
Email
Gender*
- Male
- Female
- Prefer not to disclose
Veteran*
- Yes
- No
Race*
- White
- Black
- Hispanic
- Indian
- Asian
Marital Status*
- Married
- Single
- Widowed
- Divorced
Do you live alone?*
- Yes
- No
Physical Condition*
- Mobile
- Cane
- Wheelchair
- Walker
Cafe Site*

I have an illness that made me change the kind/amount of food I eat.*
- No (0)
- Yes (2)
I eat fewer than 2 meals per day.*
- No (0)
- Yes (3)
I eat few fruits or vegetables, or milk products.*
- No (0)
- Yes (2)
I have 3 or more drinks of beer, liquor, or wine (almost every day).*
- No (0)
- Yes (2)
I have teeth or mouth problems that make it hard for me to eat.*
- No (0)
- Yes (2)
I don't always have enough money to buy the food I need.*
- No (0)
- Yes (4)
I eat alone most of the time.*
- No (0)
- Yes (1)
I take 3 or more different prescribed or over-the-counter drugs per day.*
- No (0)
- Yes (1)
Without wanting to, I have lost or gained 10 pounds in the last 6 months.*
- No (0)
- Yes (2)
I am not always physically able to shop, cook, and/or feed myself.*
- No (0)
- Yes (2)
Total
You are at a moderate nutritional risk if you scored between 0 and 2. You are at a high nutritional risk if you scored between 3 and 5.
If you are at high risk, 6 and above, would you like a wellness consultation?*
- Yes
- No
Please type your name here (this will be used as your signature)*
Date
MM slash DD slash YYYY
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