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Step One

Welcome! Please tell us a bit about yourself so we can offer services that best meet your needs. We ask for demographic information to meet requirements from our funders. All your personal information is confidential. Please see the attached FAQs for more information and guidance on filling out this form.
Congregate Meal Site: JOSEPH EDWARDS
Date*
Date
Contact & Demographic Information:
First Name*
Middle Name
Last Name*
Nickname
Date of Birth*
Date of Birth
Age*
Home Address*
Line 2 (Apt/Unit/Floor #)
City*
Zip Code*
County*
State*
Mailing Address Same as Home Address?*
1. Yes
2. No
Mailing Address
Line 2 (Apt/Unit/Floor #)
City
Zip Code
County
State
Home Location Comments (additional directions for home or mailing address)
Home Phone*
Cell Phone
Email *
Gender*
1. Male
2. Female
3. Non-Binary/Third Gender
Identify as:*
1. Transgender
2. Cisgender (identify with your gender from birth)
3. Gender, if not listed
Gender (if not listed)
Ethnicity*
1. Hispanic or Latino
2. Not Hispanic or Latino
Race, Select All that Apply
1. American Indian or Alaska Native
2. Asian or Asian American
3. Black or African American
4. Middle Eastern or North African
1. Native Hawaiian or Pacific Islander
2. White
3. Race Not Included
Race, if not listed
Do You Live:*
1. Alone
2. With Others
Number of People in your household (including you):
Is your income above or below the amount listed for your household size*
1. Above
2. At/Below
Household Size Monthly Income Annual Income
1 $1255 $15060
2 $1703 $20440
3 $2152 $25820
4 $2600 $31200
5 $3048 $36580
6 $3497 $41960
7 $3945 $47340
8 $4393 $52720
For each additional person, add $5380 to annual income
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Household Size	Monthly Income	Annual Income
1	$1255	$15060
2	$1703	$20440
3	$2152	$25820
4	$2600	$31200
5	$3048	$36580
6	$3497	$41960
7	$3945	$47340
8	$4393	$52720
For each additional person, add $5380 to annual income

Step Two

Communication & Service Needs
Primary Language*
1. English
2. Spanish
3. Other
Other
Health Insurance (Select All That Apply)*
1. Medicare
2. Medicare Advantage
3. Medicaid
4. Medicaid Waiver
1. Private
2. None
3. Other
Other
Would You Like to Hear About Other Services*
1. Yes
2. No
How Can We Contact You?
1. Email
2. Mail
3. Phone
What Services are You Interested In?
Emergency Contact
Name*
Phone*
Relationship*
Nutrition Screening
Do you have an illness or condition that has made you change the kind and/or amount of food you eat?*
1. Yes
2. No
Do you eat fewer than 2 meals per day?*
1. Yes
2. No
Do you eat few fruits, vegetables, or milk products?*
1. Yes
2. No
Do you have 3 or more drinks of beer, liquor, or wine almost every day?*
1. Yes
2. No
Do you have tooth or mouth problems that make it hard for you to eat?*
1. Yes
2. No
Are there times you do not have enough money to buy the food you need?*
1. Yes
2. No
Do you eat alone most of the time?*
1. Yes
2. No
Do you take 3 or more different prescribed or over the counter drugs a day?*
1. Yes
2. No
Without wanting to, have you lost or gained 10 pounds in the last 6 months?*
1. Yes
2. No

Are there times you’re physically unable to shop, cook, and/or feed yourself?*

Yes
No

Nutrition Risk Score Questions	Yes Score
Do you have an illness or condition that has made you change the kind and/or amount of food you eat?	2
Do you eat fewer than 2 meals per day?	3
Do you eat fewer than 2 meals per day?	2
Do you have 3 or more drinks of beer, liquor, or wine almost everyday?	2
Do you have tooth or mouth problems that make it hard for you to eat?	2
Are there times you do not have enough money to buy the food you need?	4
Do you eat alone most of the time?	1
Do you take 3 or more different prescribed or over the counter drugs a day?	1
Without wanting to, have you lost or gained 10 pounds in the last 6 months?	2
Are there times you’re physically unable to shop, cook, and/or feed yourself?	2

Total Nutrition Risk Score: 0-2 = No Risk, 3-5 = Moderate Risk, 6 or more = High Risk
If you are at high nutrition risk – take action! Speak with a qualified health or social service professional about your nutritional health. Providers – if the client is at high nutrition risk, please make a case note in SUDS and make the appropriate referral
Are You Interested in Receiving Nutrition Counseling?*
1. Yes
2. No
If yes, you're invited to enroll in Text2LiveHealthy, a nutrition education program delivered to you via text message. Scan this QR code with your phone’s camera to enroll or text the word FRUIT to 97699.
Message & Data Rates May Apply. Text HELP for information. Text STOP to97699 to opt out. No purchase necessary. For Privacy Policy and Terms and Conditions, visit: https://coloradosph.cuanschutz.edu/text2livehealthy
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Disclosures and Waivers

Disclosures and Waivers
I have been informed of the policies regarding voluntary contributions, complaint procedures and appeal rights. I am aware that in order to receive requested services, it may be necessary to share information with other departments or service providers and I give my consent to do so.
Name*
Date*
Date

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Congregate Nutrition Assessment Form

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Contact & Demographic Information:

Step Two

Communication & Service Needs

Emergency Contact

Nutrition Screening

Disclosures and Waivers

Disclosures and Waivers

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