you know when you see a certain birthday card,you just know its right. anyway happy birthday worz.
-MEALS ON WHEELS APPLICATION FORM- ------------------------------------------------------------------------------
First Name: Last Name: MI:
Street:
Complex:
(if apartment)
City:
Phone: ( ) -
Birthday: MonthJanuaryFebruaryMarc
hAprilMayJuneJulyAugustS
eptemberOctoberNovemberD
ecember Day123456789101112131415
161718192021222324252627
28293031
Gender: MaleFemale
Do you reside in unincorporated King County? UnknownYesNo
Select the service(s) that you are applying for: Meals on Wheels NoYes Mobile Market NoYes
Select the reason for needing the service Select from listLong Term HomeboundTemporarily HomeboundHomebound some days, not alwaysCaregiver or Disabled person living with client
Clearly describe the physical problem causing you to need this service:
Please enter your doctor's name and phone number:
( ) -
Please enter an Emergency Contact Person not living with you:
Relationship:
Home Phone: ( ) - Work Phone: ( ) -
Who referred you to us?
If you use other support services, please indicate one of them below:
(This includes chore, visiting nurse services, case management, etc.)
Agency: Contact:
Phone: ( ) -
Select your ethnic origin: Select from listUnknownAmerican IndianAsianBlackPacific IslanderHispanicNon-MinorityOtherMulti-Racial If other, state ethnic origin:
Estimate your monthly household income: Select From List0 Person Household - Unknown1 Person Household - Less than $1,4752 Person Household - Less than $1,6871 Person Household - $1,476 to $2,4582 Person Household - $1,688 to $2,8081 Person Household - $2,459 to $3,7332 Person Household - $2,809 to $4,2671 Person Household - More than $3,7342 Person Household - More than $4,268
Please answer the following questions to help us serve you better:
Do you live alone? YesNo
Are you eligible for foodstamps? YesNo If yes, do you use them? YesNo
Do you speak English well? YesNo
Are you on a physician-prescribed diet? YesNo If yes, what type of diet?
Please answer ALL of the following Yes/No questions:
Do you have an illness or condition that has made you change the kind or amount of food you eat?
YesNo
Do you eat fewer than 2 meals per day? YesNo
Do you eat few fruits or vegetable and/or milk products per day?
This means less than 2 servings of fruit (including juice), less than 3 servings of vegetable, and/or less tha 2 servings of milk products per day. YesNo
Do you have 3 or more drinks of beer, liquor, or wine almost every day? YesNo
Do you have tooth or mouth problems that make it hard for you to eat? YesNo
Do you sometimes run out of money to buy food? YesNo
Do you eat alone most of the time? YesNo
Do you take 3 or more different prescribed and/or over-the-counter drugs per day? YesNo
Have you lost or gained 10 pounds in the last 6 months without trying? YesNo
Is it difficult for you to shop, cook, or feed yourself at times? YesNo
Please select from the following list the activities you need assistance with:
Eating
Bathing
Toileting
Walking
Transferring in/out of bed/chair
Getting Places
Managing your medications
Dressing Cooking
Shopping
Chores
Driving
Heavy Housework
Phoning
None of these
If someone else assisted in completing the form please indicate here:
Name: Agency:
Phone: ( ) -
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This page was last revised on February 12, 2009.
© 2009 Senior Services. All rights reserved.
