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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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
Please choose your site.
Alexandria "The Hub"
Centerville-Abington
Daleville - Salem Place
Fayette County Senior Center
Franklin County Senior Center
Gas City
Gillespie Towers (available to residents only)
Grant County Senior Center
Hoosier Place Senior Housing (available to residents only)
Jay County Community Center
Longfellow Plaza (available to residents only)
Muncie Delaware County Senior Center
Nettle Creek Senior Center
New Castle Senior Center
Parker City
Pendleton Library
Richmond Senior Community Center
Rush County Senior Center
Sherman Street
Southdale Towers (available to residents only)
Southview Courts (available to residents only)
Western-Wayne Senior Center
Winchester Fairgrounds
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
CAPTCHA
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