Congregate Meals Form Version-2

Congregate Meals Form

Registration

Registration- Assessment Form

Required for All Registered Programs

Personal Data (Please Print):

Residential Address

Mailing Address:

Title IIIC Eligibility:

Are you age 60 or over?

Last 4 digits Social Security# Optional

Emergency Contact:

Living Arrangement:

Federal Poverty Level (FPL):$1,304/mo or $15,650 annual

Proficient in English?

Race: (Please check all that apply)

Ethnicity:

What was your sex at birth?

What is your gender?( Check only one)

How do you describe your sexual orientation or sexual identity?

SECTION 2 – Nutritional Assessment and Veteran Status
Registration and Assessment (July 2023-June 2024)
* Required for (IIIC): In-Person Congregate Meals

Functional: Activities of Daily Living and Instrumental Activities of Daily Living

ADLs:
Eating
Clear
Dressing
Clear
Transferring In/out of Bed/Chair
Clear
Bathing
Clear
Toileting
Clear
Walking
Clear
IADLs:
Light Housework
Clear
Shopping
Clear
Meal Preparation
Clear
Transportation
Clear
Medication Management
Clear
Money Management
Clear
Heavy Housework
Clear
Using Telephone
Clear

Nutritional Assessment:

I have an illness or condition that made me change the kind and/or amount of food I eat.
Clear
I eat fewer than 2 meals per day.
Clear
I eat few fruits or vegetables or milk products.
Clear
I have 3 or more drinks of beer, liquor, or wine almost every day.
Clear
I have tooth or mouth problems that make it hard for me to eat.
Clear
I don’t always have enough money to buy the food I need.
Clear
I eat alone most of the time.
Clear
I take 3 or more different prescribed or over–the-counter drugs a day.
Clear
Without wanting to, I have lost or gained 10 pounds in the past 6 months.
Clear
I am not always physically able to shop, cook, and/or feed myself.
Clear

Veteran Status

Have you ever served in the United States military?
Are you the spouse, legal partner, parent, or child of a person who is serving in or who has served in the United States military?
If you identify as being military affiliated, check below if: “I consent to this agency and the California Department of Aging transmitting my name, email address, mailing address, and mobile telephone number to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which I may be eligible. I understand that this consent is valid for 12 months.”
Contact the California Department of Veterans Affairs (CalVet) to determine eligibility for services and supports at www.calvet.ca.gov or 1-800-952-5626.

Consent

Congregate Meals program must communicate your information to the network of partners and providers to carry out services for you. Services cannot be completed without these exchanges. Congregate Meals program uses your information in the following ways. By signing, you give permission to:

  • Share your information with the San Joaquin County Senior Nutrition and congregate meals site.
  • Prepare and submit referrals, as needed, for social services to other programs on your behalf.
  • Submit your data to California Department of Aging or any other program funder for reporting purposes.
  • Provide San Joaquin Office of Emergency Services your information in cases of widespread disasters.