AGING & DISABILITY NETWORK CONSUMER INTAKE FORM FY19/20
The service you are receiving is paid for in whole or in part by funds from the federal Older American’s Act and
the State of Iowa. Your responses on this form are confidential. The Department on Aging uses this important
information to research the needs of older Iowans. Thank you for providing your information.
Today's Date: _________________________
Last Name: ______________________________ First: _____________________________ MI: ____
Date of Birth: ________ /________ /____________ or Age: ________
Address: ________________________________ City: ______________ State: ____ Zip: __________
Home Phone: ( ________ ) ____________________ Cell Phone: ( ________ )___________________
Email: ______________________________________________________________________
Demographic Information
Do you live alone? Yes No Number in Household Including Yourself: _____
Please Check Your Annual Total Household Income Range:
Veteran Status:
Not a Veteran
Veteran
Gender: Female
Male
Other
Race: White
American Indian/Alaskan Native
Asian
African American/Black
Native Hawaiian/Other Pacific Islander
Yes
No
Are You Hispanic or Latino:
Primary Language:
English Other: _________________________________
Does Medicaid pay for some of the services you receive in your home, such as homemaker, meals,
transportation, organizing your medications, or bathing assistance?
Yes
No
Don't Know
In the past 30 days, how often were these statements true:
I have worried whether my food would run out before I got money to buy more.
Often
Sometimes
Never
The food that I bought just didn’t last and I didn’t have money to get more.
Often
Sometimes
Never
$0 - $12,490
$21,331 - $25,750
$34,591 - $39,010
$12,491 - $16,910
$25,751 - $30,170
$39,011 - $43,430
$16,911 - $21,330
$30,171 - $34,590
$43,431 - or Above
Veteran Spouse/Dependent
Other
During the past 7 days, how would you rate your ability to complete these routine activities?
I didn't
need help
I needed help
sometimes
I always
needed help
Activity did
not occur
Shop?
Manage your
medications?
Prepare meals?
Use
transportation?
How would you rate your ability to complete these activities?
Do heavy
housework?
Do light
housework?
Use
the telephone?
During the past 7 days, how would you rate your ability to complete these physical activities?
Walk?
Bathe?
Dress?
Get out of bed
or chair?
Use the toilet?
Eat?
I don't
need help
I need help
sometimes
I always
need help
Activity does
not occur
Manage money?
I didn't
need help
I needed help
sometimes
I always
needed help
AGING & DISABILITY NETWORK CONSUMER INTAKE FORM
Consumer: __________________________
AGING & DISABILITY NETWORK CONSUMER INTAKE FORM
Consumer: __________________________
IADL ‐ Data Entry
0
1
2 3
IADL ‐ Data Entry 0 1
2 3
IADL ‐ Data Entry 0
1 2
Congregate Meals
Case Management
Nutrition Counseling
Nutrition Education
EAPA Assessment and Intervention
AGING & DISABILITY NETWORK CONSUMER INTAKE FORM
Consumer: __________________________
Nutrition Risk Screening
Yes
No
I have an illness or condition that made me change the kind and/or
amount of food I eat.
Yes
No
I eat fewer than two meals per day.
Yes
No
I eat few fruits. (Less than 1 ½ cups daily)
Yes
No
I eat few vegetables. (Less than 2 cups daily)
Yes
No
I eat and/or drink few milk products. (Less than 3 cups daily)
Yes
No
I have three or more drinks of beer, liquor or wine almost every day.
Yes
No
I have tooth or mouth problems that make it hard for me to eat.
Yes
No
I don’t always have enough money to buy the food I need.
Yes
No
I eat alone most of the time.
Yes
No
I take 3 or more different prescribed or over-the-counter drugs a day.
Yes
No
I have gained OR lost 10 pounds in the last 6 months without wanting to.
Yes
No
I am not always physically able to do one or more of: shopping, cooking,
or feeding myself.
The section below to be completed by provider ONLY.
Provider / Site: ___________________________________________________________
NEW Intake Form:
UPDATED Intake Form:
Check the box next to the service provided:
Home Delivered Meals
Options Counseling