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
