Form DAAS101

Client Registration Form

Client Registration Form

Legal Name
Address
MM slash DD slash YYYY
Max. file size: 256 MB.
Sex
At or Below Poverty Level?
Marital Status
Household Size
Ethnicity
(Are you of hispanic or latino origin?)
Client's Overall Functional Status
Enter the client self-reported overall functional status here. If the client receives other services in addition to congregate nutrition and transportation, use the DAAS-101 Long Form to register the client and complete section IV to report functional status.
Nutrition Health Score
Do you have an illness or condition that made you change the kind and/or amount of food you eat?
Do you have tooth/mouth problems that make it hard for you to eat?
Do you have enough money or food stamps to buy the food you need?
Have you lost 10 or more pounds in the past 6 months without trying?
Have you gained 10 or more pounds in the past 6 months without trying?
Are you physically able to shop for yourself?
Are you physically able to cook for yourself?
Are you physically able to feed yourself?
Required For All Clients I, the client, understand that the information contained on this form will be kept confidential unless disclosure is required by court order or for authorized federal, state or local program reporting and monitoring. I understand that any entitlement I may have to Social Security benefits or ther federal state sponsored benefits shall not be affected by the provision of the aforemention information. My signature authorizes the providing agency to begin the service(s) requested.

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