_______

Go & Dine

NUTRITION SITE and NUMBER: CLIENT NO:

DATE: Gender: Male Female DOB: Veteran: Yes No

Last Name: First Name: Mid Init 

Address:

City: State: Zip:

Phone: Frail\Disabled: Yes No

Emergency Contact: Relationship: Phone:

Living Status: Alone, With Spouse Only, With relatives, With non-relatives, With Spouse and others, Others

Marital Status: Married Widowed Divorced Never Married Domestic Partner or

Significant Other 

Number in 

Race: White Black American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander

Other Race 2 or More Races White (Alone) Hispanic

Ethnicity: Hispanic Non-Hispanic

1 person monthly income: less than $1012 Between $1013 $1265 Between $1266 $1518 Greater than $1519

2 person monthly income: less than$1372 Between $1373 - $1715 Between $1716 $2058 Greater than $2059

Read the statements below. Circle the number in the "YES" column for those that apply to you.

Circle Number below if YES (if NO leave blank)

I have an illness/condition that made me change the kind/amount of food I eat. 2

I eat fewer than 2 meals a day. 3

I eat few fruits or vegetables, or milk products. 2

I have 3 or more drinks of beer, liquor or wine almost every day. 2

I have tooth or mouth problems that make it hard for me to eat. 2

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. 2

I am not always physically able to shop, cook and/or feed myself. 2

Total

A score of 0-2 means Good. You could recheck at six months.

A score of 3-5 means you are at moderate nutritional risk. You could see what you can do to improve eating habits and 

make life-style changes.

A score of 6 or more means you are at a high nutritional risk. You could take the checklist to a doctor, dietitian or 

qualified health or social service professional and talk to them. Ask for definite ways to improve your nutritional health.

Rev 3/2018 pg 1 of 2

2020 NEW: ____________

UPDATE: ____________

REGISTRATION FORM

Household:

Total your nutritional score and compare below.
Informed Consent to Capture and Record Personal Information 

I hereby consent to my personal information contained in this Registration Form being saved in the 

Client Data System maintained by the New York State Office for the Aging and used by the local Office 

for the Aging. I understand that my information will not be shared with other agencies without my 

permission. 

I understand that the information on this form may be sent to the State and federal government, and is 

used to improve the services offered and better meet my needs. 

_______________________________ ______________ 

Signature Date 

_______________________________ 

Print 

ATTESTATION 

To be completed by worker 

I attest that informed consent, as indicated, was obtained from the above individual, who provided 

his/her signature above. All appropriate processes were followed, and consent was provided 

voluntarily. 

_________________________________________ _____________________ 

Worker Signature Date

_______________________ 

Worker Name (Print) 

_________________________________________ 

Congregate Site 

Revised 3/2018 pg 2 of 2