Meals on Wheels/Mobile Market Online Application


Meals on Wheels/Mobile Market Application

First Name:

Last Name:

Middle Initial:

Street:

Complex:
(if apartment)

City:

State:

Zip:

Phone:

( ) -

Birthday:

Gender:

Do you reside in unincorporated King County?

Select the service(s) that you are applying for:

Meals on Wheels

Mobile Market

Select the reason for needing the service

Clearly describe the physical problem causing you to need this service:

Please enter your doctor's name and phone number:

( ) -

Please enter an Emergency Contact Person not living with you:

Relationship:
Home Phone: ( ) - Work Phone: ( ) -

Who referred you to us?

If you use other support services, please indicate one of them below:
(This includes chore, visiting nurse services, case management, etc.)
Agency: Contact:
Phone: ( ) -

Select your ethnic origin:

If other, state ethnic origin:

Estimate your monthly household income:

Please answer the following questions to help us serve you better:
Do you live alone?
Are you eligible for foodstamps? If yes, do you use them?
Do you speak English well?
Are you on a physician-prescribed diet? If yes, what type of diet?

Please answer ALL of the following Yes/No questions:
Do you have an illness or condition that has made you change the kind or amount of food you eat?
Do you eat fewer than 2 meals per day?
Do you eat few fruits or vegetable and/or milk products per day?
This means less than 2 servings of fruit (including juice), less than 3 servings of vegetable, and/or less tha 2 servings of milk products per day.
Do you have 3 or more drinks of beer, liquor, or wine almost every day?
Do you have tooth or mouth problems that make it hard for you to eat?
Do you sometimes run out of money to buy food?
Do you eat alone most of the time?
Do you take 3 or more different prescribed and/or over-the-counter drugs per day?
Have you lost or gained 10 pounds in the last 6 months without trying?
Is it difficult for you to shop, cook, or feed yourself at times?

Please select from the following list the activities you need assistance with:
Eating Bathing Toileting Walking Transferring in/out of bed/chair Getting Places Managing your medications Dressing	Cooking Shopping Chores Driving Heavy Housework Phoning None of these

If someone else assisted in completing the form please indicate here:
Name: Agency:
Phone: ( ) -

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