_________________________________ Center - Meal Client Registration
Client information Last Name
First Name
Date___________/____________2017
Ethnicity (select one) Not Hispanic/Latino
Hispanic/Latino
Race (select one or more; information collected for federal statistics)
Nickname or Preferred Name
Address
American Indian/ Alaskan Native
City
White
Black/African American
Telephone Number
Home (
)
Mobile (
)
Primary
Veteran of US Armed Service Yes
Date of Birth Month
/
Day
Year
Pacific Islander/Native Hawaiian
Other
Sex/Gender Female Male Other
Intersex
Transgender
Sexual Orientation (optional): Heterosexual/Straight Lesbian/Gay Bisexual Unsure If not listed above, please specify.
No
Income (select one) $1005. month or below (1-person household) $1353. month or below (2-person household) /
Asian
$1006. month or above (1-person household) $1354. month or above (2-person household
Unknown
Emergency Contacts Name
Name:
Relationship to Client:
Relationship to Client:
Home Tele.
Primary
Mobile Tele.
Primary
Primary Physician
Home Tele.
Primary
Mobile Tele.
Primary
Physician’s Tel
Check each question below: Yes Live alone Frail/ Disabled Having a physical or mental disability that restricts the ability of an individual to perform normal daily tasks, or threatens
No
the capacity of the individual to live independently. Vulnerable Exposed to unfavorable environmental conditions, or lack of social resources such as language barrier, isolation, no informal support system, income level between 100-200% of the poverty level, or not previously within the service system.
************************* ADL/IADLs Required for Home Delivered Supplemental meals ONLY ***************************************** INSTRUMENTAL ACTVITIES OF DAILY LIVING In the last 7-days, if you’ve had some difficulty in performing any of the following tasks by yourself, or required personal or standby assistance, or supervision, check ‘impairment’.
1. 2. 3. 4.
Preparing Meals……………………. Laundry/Ordinary Housework… Heavy Housework………………….. Shopping………………………………..
Impairment Impairment Impairment Impairment
5. Managing Medicine………………. Impairment 6. Using Transportation ……………. Impairment 7. Paying Bills/Managing Money…. Impairment 8. Using the Telephone……………… Impairment
ACTIVITIES OF DAILY LIVING In the last 7-days, if you’ve had difficulty or required any help in performing the following, check ‘impairment’.
1. Bathing…….. Impairment 2. Dressing…… Impairment 3. Eating……… Impairment
4. Getting out of the bed or chair…. Impairment 5. Walking…………………………………… Impairment 6. Toileting…………………………………. Impairment
jc/DSS/SS/Centers/NAPIS/centerregistration 2017
Name _______________________________
Date __________________
Determine Your
Center _____________________________________ The warning signs of poor nutritional health are often overlooked. Use this survey to Your find out if you are at nutritional risk.
Nutritional Health
Read the statements below. Circle the number in the column for those that apply to you. Total your nutritional score.
Yes
No
2. I eat alone most of the time.
3 1
0 0
3. I eat less than 2 servings of milk or milk products most days; I eat 0-1 serving a day.
1
0
4. I eat less than 5 servings of fruit and/or vegetables most days.
1
0
5. I have 3 or more drinks of beer, liquor, or wine almost every day.
2 2
0 0
2
0
1
0
9. I am not always physically able to shop, cook, or feed myself (or get someone to do it for me).
2
0
If 'Yes' to ANY OF THESE, circle 'Yes'. 10. I have problems with my teeth or mouth that make it hard to eat some foods.
2
0
11. I sometimes run out of money to buy the food that I need.
4
0
1. I eat fewer than 2 meals a day; I eat mostly snacks or 1 complete meal a day.
6. Without wanting to, I have lost or gained 10 pounds in the last 6 months. lost or gained 7. I have an illness or health condition (such as diabetes, high blood pressure, high cholesterol) that made me change the kind and/or amount of food that I eat. 8. I take 3 or more different prescribed or over-the-counter drugs every day. Examples: I need help going food shopping, I need help cooking a meal, or I need help cutting up food on my plate.
TOTAL
Total your nutritional score. If it’s …. 0-2 Good!
Recheck your nutritional score in 6 months.
3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Recheck your nutritional score in 3 months. 6 or more You are at high nutritional risk. Bring this survey the next time you see your doctor, or check the box below to speak with a registered dietitian free of charge.
No, I'm not interested.
Yes, I'd like to discuss this survey with a nutrition professional
Male Female Height _________ Weight ________ (lbs) (_______)_______________________
Tel. #