Free 02AG004E (AG-2-B) - Oklahoma

*02AG004E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

OLDER AMERICAN ACT ASSESSMENT Please update any information below that has changed since last year's Older American Act Assessment.
Current name Former last name, if changed Address City
Private residence Nursing home Yes Above No Below One person Refused Two persons

Social Security number

Date of birth

State

Zip

Current phone number

Type of residence:
Lives alone: Poverty level: Monthly income: $

Housing complex Other (specify)

Change in primary doctor:
Name City

Current medical condition/illnesses:

Change in emergency contact(s):
Name Relationship Phone

If no changes are needed to the above information, please check this box , complete the reverse side of this form, provide your signature, location/project name, today's date, and return to the appropriate staff.
Signature Location/project name Date submitted

FOR OFFICE USE ONLY: Participant status: Active Inactive Terminated Reason for termination: Participant has special eligibility, if not currently age 60 or older: Eligible spouse Handicap/disabled, lives in elder housing where a congregate nutrition site is located. Meal volunteer Handicap/disabled, lives with participant.
OKDHS revised 8-13-2003 02AG004E (AG-2-B)

02AG004E (AG-2-B)

Change of Client Status

DETERMINE YOUR NUTRITIONAL HEALTH
The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you are at nutritional risk. Read the statements below. Circle number in the yes column for those that apply to you. Total the nutritional score. Yes
I have an illness or condition that made me change the kind and amount of food I eat......................................2 · What illness? · How does this affect your diet or ability to eat? I eat fewer than two meals per day. ........................................................................................................3 · How many meals/day? · How many snacks/day? · If under two, what is the problem? I eat few fruits, vegetables, or milk products...........................................................................................2 · How many fruits/week? · Which ones? · How many vegetables/week? · Which ones? · How many milk products/week? · Which ones? I have three or more drinks of beer, liquor, or wine almost every day ................................................... 2 · Which ones? I have tooth or mouth problems that make it hard for me to eat ............................................................ 2 · What type of problems? · How do you modify your diet to accommodate this? I don't always have enough money to buy the food I need.................................................................... 4 · How often do you feel you cannot afford groceries? · What limits you? I eat alone most of the time.................................................................................................................... 1 · Do you prefer to eat alone? · What about congregate settings? · Eat fast food? · Interested in cooking? · Interested in shopping? I take three or more different prescribed (RX) or over-the-counter (OTC) drugs a day.................................. 1 · Which one: OTC or Rx? · What are they used for? Without wanting to, I have lost or gained ten pounds in the last six months ............................................ 2 · Which one: Lost/gained · Do you know why this happened? I am not always physically able to shop, cook, and/or feed myself ....................................................... 2 · Which one: Shop/feed/cook · Why? · Who provides the service for you?

*7Q1A1*

*7Q2A1*

*7Q3A1*

*7Q4A1* *7Q5A1* *7Q6A1* *7Q7A1*

*7Q8A1* *7Q9A1* *7Q10A1*

Total nutritional score:

TOTAL ............................

0-2 .................. Good! Recheck your nutritional score in six months. 3-5 .................. You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center, or health department can help. Recheck your nutritional score in three months. 6 or more ........ You are at high nutritional risk. You are encouraged to speak with your doctor. Ask for help to improve your nutritional health. Remember that warning signs suggest risk, but do not represent diagnosis of any kind. 2 OKDHS revised 8-13-2003