Nutrition Intake Form Client Intake Form In order to meet state requirements this form must be completed upon your first visit to a meal site. Step 1 of 2 50% Name First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Phone*Gender*MaleFemalePrefer not to discloseVeteran*YesNoRace*WhiteBlackHispanicIndianAsianMarital Status*MarriedSingleWidowedDivorcedDo you live alone?*YesNoPhysical Condition*MobileCaneWheelchairWalkerCafe Site*Centerville-AbingtonDaleville Fire StationFayette County Senior CenterForest Park Senior CenterFranklin County Senior CenterGas CityGillespie TowersHoosier Place Senior HousingJay County Community CenterLongfellow PlazaNettle Creek Senior CenterNew Castle Senior CenterPendleton LibraryRichmond Senior Community CenterRush County Senior CenterSherman StreetSouth View CourtsWestern-Wayne Senior Center 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 the score of all items chosen and record here:*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. SignatureInitials
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