HomeMy WebLinkAbout8.1 Attch 2 Annual Registration Form
Alameda County Area Agency on Aging
OLDER AMERICANSlOLDER CALIFORNIAN ACT/COUNTY GENERAL FUND PROGRAMS
REGISTRATION FORM
(Registration Rev. 5110)
[1] Provider Number: 0703 [2] Provider Name: Spectrum Communitv Services
SRe Number: 2308 Progam Category: Congrezate -Dublin Senior Center
[3] Registration Date: [4] ID: Number:
Date of intake in current fiscal yeaz, or date client
Received service forthe first time in fiscal ear.
[5] Name Phone
Address
Emergency Contact
Name Address Phone
Regulaz Physician
Name Phone
[6] Birth Date (MM/DD/PYYY):
If applicant declines to state, enter 01/01 +the year of b irth that would make the indiv idual at least 60 yrs. old.
[7] Sex: ? Male ? Female
[8] Ethnicity/Race: ? American Indian/Alaska Native (AI)
Asian: ? Asian Indian (AS) ? Cambodian (CA) ? Chinese (CH)
? Filipino (FI) ? Japanese (JA) ? Korean (KO)
? Laotian (LA) ? Vietnamese (VI) ? OtherAsian (AO)
Native Hawaiian/ ? Gliamanian (GU) ? Hawaiian (HA) ? Samoan (SA)
Pacific Islander ? Other Pacific Islander (OP)
? African American/Black (AA) ? Caucasian (W) ? Hispanic or Latino (II)
? Some Other Race (OR) ? Race Missing (Rn
(9[ ZipCode:
[10] Does Client Live in Rural Area? Yes ? Na
Geographic place that has less than 2,500 persons and is not a suburb to a city or town.
[ll] Does Client Liw Alone? ? Yes ? No
[12] IFSINGLE, is clienYs income less than $867/monthY ? Yes ? No
IF MARRIED, is client's joint income less than $1,167/month? ? Yes ? No
[13] Nutritional Risk Score:
Required for Home-Delivered Meals, Congregate Meals, Case Management, Adult Day Care, Alzheimer's Day
Care Resource Centers, Disease Prevention/Health Services.
[14] Without help, client is iJNABLE TO PERFORM:
? Fating ? Preparing meals
? Dressing ? Shopping for personal items
? Bathing ? Managing medications
? Toileting ? Managing money
? Getting in/out of bed ? iJsing telephone
? Walking ? Doing heavy housework
? Doing Light housework
? Transportation ability
Total # ADLProblems Total# IADL ProMems
Kequired for Aduk Day Care, Alzheimer's Day Care Resource Centers, Case Management, Community Services &
Senior Center Management, Congregate Meals, Disease Prevention & Health Promotion, ElderAbuse Prevention,
Health Services, Home-Delivered Meals, Homemaker (In-Home Services), Linkages, & Personal Care.
Completed By: Date:
Si nature Contrnued on other side...
ATTACHMENT 2
NUTRITION SCREENING INTTIATIVE
Read the statement below. C ffcle the number in the "yes" column for those that apply. For each
"yes" answer, score the number in the box Total the nutritional score. Enter the numerical
score on the AAA 101 in the column tIIled "Nutritional Risk."
YES
I have an illness or condition that made me change the kind and/or amount of food Z
I eat.
I eat fewer than 2 meaLs per day. 3
I eat few fruits or vegetabks, or millc products. 2
I have 3 or more drinks ofbeer, liquor or wine almost every day. 2
I have tooth or mouth problems that make it hard for me to eat. Z
I don't always have enough money to buy the food I need. 4
I eat alone most of the time. 1
I take 3 or more different prescribed or over-the-counter drugs a day. 1
Without wanting to, I have lost or gained 10 pounds in the last 6 months. Z
I am not always physically able to shop, cook and/or feed myself. 2
TOTAL
(T'ransfer the score to the other side of this Registration Form)
~