Form DAAS101 Client Registration Form Client Registration Form Legal Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Last 4 Digit SSN Date Of Birth MM slash DD slash YYYY Email Phone NumberDriver LicenseMax. file size: 256 MB.Sex Male Female At or Below Poverty Level? Yes No Marital Status Single (never married) Married Single (divorced/widowed) Refured to answer Household Size Lives alone 2 in home 3 or more in home Group /shared home Refused to answer Ethnicity(Are you of hispanic or latino origin?) Not Hispanic or Latino Hispanic Puerto Rican Hispanic Mexican American Unreported Hispanic Cuban Hispanic Other Primary Language Spoken in Home Day Phone NumberEvening Phone NumberClient's Overall Functional StatusEnter 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. Well At Risk High Risk Nutrition Health ScoreDo you have an illness or condition that made you change the kind and/or amount of food you eat? Yes No How many meals do you eat per day?How many servings of fruit per day?How many servings of vegetables per day?How many servings of milk/dairy products per day?How many drinks of beer, liquor, or wine do you have every day or almost every day?Do you have tooth/mouth problems that make it hard for you to eat? Yes No Do you have enough money or food stamps to buy the food you need? Yes No How many meals do you eat alone daily?How many prescribed drugs do you take per day?How many over-the-counter drugs do you take per day?Have you lost 10 or more pounds in the past 6 months without trying? Yes No Have you gained 10 or more pounds in the past 6 months without trying? Yes No Are you physically able to shop for yourself? Yes No Are you physically able to cook for yourself? Yes No Are you physically able to feed yourself? Yes No 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. Signature
