2. Date:*
   ##/##/####
3. Referred by:
4. Relationship:
5. Phone:
   ###-###-####
7. Applicant Information
9. First Name*
10. Last Name*
11. Middle Initial
13. Address1*
14. Apartment/Unit #
16. City*
17. State*
18. Zip*
20. Apartment Complex/Neighborhood
21. Primary Phone #*
    ###-###-####
22. Secondary Phone #
    ###-###-####
24. Email
25. Date of Birth*
    ##/##/####
26. Age*
28. How many individuals live in the home?*
    #
29. Name/Relationship
31. What is you primary language?*

    1. English
    2. Spanish
    3. Other
32. Please specify other language
33. Do you require any hearing, vision, or language assistance?

    1. Yes
    2. Language Interpreter
    3. ASL Interpreter
    4. No
35. Contact Instructions
36. Contact

    Please check one

    1. Call Applicant
    2. Call Contact Below
38. Contact First Name*
39. Contact Last Name*
40. Contact Relationship
41. Contact Phone #
    ### ### ####
43. Is there anything else we should know when contacting you?
47. Applicant Demographic Information
49. What sex do you identify as?*

    1. Female
    2. Male
    3. Transgender/Other
    4. Declined
50. Ethnicity

    1. Hispanic/Latino
    2. Not Hispanic/Latino
    3. Declined
51. Race

    Check all that apply

    1. American Indian/Alaskan
    2. Native Asian/Pacific Islander
    3. African-American
    4. White/Caucasian
    5. Other
    6. Declined to answer
52. Race - Other
54. Marital Status*

    1. Single
    2. Married
    3. Widowed
    4. Divorced
    5. Separated
    6. Unknown
    7. Declined
55. Did you or your spouse serve in the military?

    1. Yes
    2. No
    3. Declined
56. Military - if yes, who served?
58. Are you a registered voter?

    1. Yes
    2. No
    3. Need application form
    4. Decline
59. Are there firearms or other weapons in the home?*

    1. Yes
    2. No

    Please be advised that all weapons are required to be unloaded and stored in a safe and secure manner when volunteers and staff make meal deliveries and home visits. Failure to do so could result in immediate suspension or termination of Meals on Wheels/Home Delivered Meals service.
60. Pets in the house?

    1. Dog
    2. Cat
    3. Other
    4. Need assistance with pet food?
62. Maryland Department of Aging - Food Security Screen
64. 1. If you had groceries available, would you be able to use them to prepare meals?*

    1. Yes (Skip to Question 3)
    2. No (Go to Question 2)
65. 2. Do you have reliable help with meal preparation?*

    1. Yes (Continue to Question 3)
    2. No ( Applicant is LEVEL A priority) Skip to Page 3
67. During the last month...
69. 3. How often was this statement ? "The food that I bought just didn't last, and we didn't have money to get more."*

    1. Often (1 point)
    2. Sometimes (1 point)
    3. Never (0 Points)
70. 4. How often was this statement true? "We couldn't afford to eat balanced meals."

    1. Often (1 point)
    2. Sometimes (1 point)
    3. Never (0 points)
72. 5. Did you or other adults in your household ever cut the size of your meals because there wasn't enough money for food?*

    1. Yes, on 3 or more days (1 point
    2. Yes, on 1 or 2 days (1 point)
    3. No (0 points)
73. 6. Did you or other adults in your household ever skip meals because there wasn't enough money for food?*

    1. Yes, on 3 or more days (1 point)
    2. Yes, on 1 or 2 days (1 point)
    3. No (0 points)
75. 7. Did you ever eat less than you felt you should because there wasn't enough money for food?*

    1. Yes (1 point)
    2. No (0 points)
76. 8. Were you ever hungry but didn't eat because you couldn't afford enough food?*

    1. Yes (1 point)
    2. No (0 points)
78. Add the points from Question 3-8 and enter in this blank
    #
79. 9. Are you able to get groceries into your home when you need them?*

    1. Yes
    2. No
81. Transportation
83. Do you drive?*

    1. Yes
    2. No
84. Drive - If yes, how often and purpose?
85. Do you use a van service?

    1. Yes
    2. No
87. Do you depend on public but service?*

    1. Yes
    2. No
88. Do you depend on family and friends?*

    1. Yes
    2. No
90. Do you depend on a volunteer group?*

    1. Yes
    2. No
91. Volunteer group - If yes, what group?
93. Nutrition Screen
95. Do you have a dietary influenced illness?*

    1. Yes
    2. No
96. Do you eat less than 2 meals per day?*

    1. Yes
    2. No
97. Do you have 3 or more alcoholic drinks per day?*

    1. Yes
    2. No
99. Do you eat less than 5 servings of fruits, vegetables, and dairy products per day?*

    1. Yes
    2. No
100. Do you have tooth or mouth problems making it difficult to chew or eat?*

     1. Yes
     2. No
101. Do you lack money to buy food on a regular basis?*

     1. Yes
     2. No
103. Do you usually eat alone?*

     1. Yes
     2. No
104. Do you use 3 or more prescription and/or over the counter medications each day?*

     1. Yes
     2. No
105. Have you lost or gained 10 pounds in the last 6 months without trying?*

     1. Yes
     2. No
106. Are you unable to shop for food, cook, or eat regularly?*

     1. Yes
     2. No
108. Nutrition Screen - Number of Yes answers
109. Height*
110. Weight*
112. Diet Requirements
114. Diet Requirements*

     1. Regular Diet (A heart healthy diet designed to be low in sodium (1,000 mg), sugar, and fat. Diet is suitable for most people, including diabetics who control their condition with diet & medication)
     2. Diabetic Diet/Low Carbohydrate*
     3. Mechanical Soft Diet*
     4. Low Cholesterol Diet*
     5. Low Sodium Diet*
     6. Other*
116. Other Diet Requirement
     Details
117. RX mg Na
     Details
119. * A prescription is required from your health care provider. Please note, not all MOW/HDM vendors preparing meals are able to provide prescription diets.
121. Do you have any severe food allergies? Please specify.*
123. While every attempt will be made to exclude allergy causing foods, the Frederick County Department of Aging and the meal vendors are not able to guarantee such food items, do not come in contact with, or are included in meals provided to Meals on Wheels/Home Delivered Meals clients. It is the individual meal recipients responsibility to examine the food provided, and avoid items that may cause an allergic reaction.
125. Please note that Maryland Department of Aging regulations require specific food components be included in the meals provided to Meals on Wheels recipients. This program does not offer individual menu choices or accommodate specific food requests and substitutions.
127. Health Conditions

     Check all that apply

     1. Arthritis
     2. Cancer
     3. Depression
     4. Dementia
     5. Diabetes

     1. Developmental/Intellectual Disability
     2. Falls in the past year
     3. Hearing Loss
     4. Heart Disease
     5. High Blood Pressure

     1. Mental Illness
     2. Parkinson's Disease
     3. Respiratory Disease
     4. Seizures
     5. Substance Abuse (Alcohol or Drug)

     1. Surgery (Recent)
     2. Stroke
     3. Tooth or Mouth Problems
     4. Traumatic Brain Injury
     5. Vision loss
129. Falls in the past year? Number?
     #
131. Other: additional conditions not listed.
133. Assistive Devices/Services
135. Mobility:

     Check all that apply

     1. Wheelchair
     2. Scooter
     3. Walker
     4. Cane
     5. Crutches
     6. Prosthetic devices
     7. Orthotic devices
136. Hearing:

     Check all that apply

     1. Hearing aid(s)
     2. Alerting devices for deaf
     3. Video remote interpreter service
     4. American Sign Language
     5. Amplified telephone
137. Vision:

     1. Low-vision magnifier
     2. Low-vision phone device
     3. Braille
139. Medication
     Please list all prescription, over-the-counter medications, and supplements
141. Medication Name
142. Dosage
143. Condition being treated
144. Notes
146. Medication Name
147. Dosage
148. Condition being treated
149. Notes
151. Medication Name
152. Dosage
153. Condition being treated
154. Notes
156. Medication Name
157. Dosage
158. Condition being treated
159. Notes
161. Medication Name
162. Dosage
163. Condition being treated
164. Notes
166. Medication Name
167. Dosage
168. Condition being treated
169. Notes
171. Medication Name
172. Dosage
173. Condition being treated
174. Notes
176. Medication Name
177. Dosage
178. Condition being treated
179. Notes
181. Medication Name
182. Dosage
183. Condition being treated
184. Notes
186. Medication Name
187. Dosage
188. Condition being treated
189. Notes
191. Primary Health Care Provider
193. Primary Health Care Provider*
194. Name*
195. Phone #*
     ###-###-####
197. FAX #
     ###-###-####
198. Address1*
200. City*
201. State*
202. Zip*
204. Emergency Contacts
206. Emergency Contact # 1*
207. Name*
208. Relationship*
210. Address1
211. City
213. State
214. Zip
215. Home Phone #
     ###-###-####
216. Cell Phone #
     ###-###-####
218. Work Phone #
     ###-###-####
219. Email Address
221. Emergency Contact #2
222. Name
223. Relationship
225. Address
226. City
228. State
229. Zip
230. Home Phone #
     ###-###-####
231. Cell Phone #
     ###-###-####
233. Work Phone #
     ###-###-####
234. Email Address
236. Person responsible for financial contributions, if not applicant
238. First Name
239. Last Name
240. Relationship
242. Address
243. City
245. State
246. Zip
247. Home Phone
     ###-###-####
248. Cell Phone #
     ###-###-####
250. Work Phone #
     ###-###-####
251. Email Address
253. Contact Person, Title
254. Phone
256. Reason for service
258. Agencies Currently Providing Assistance
260. Agencies Currently Providing Assistance
261. Contact Person, Title
262. Phone
264. Reason for service
266. Contact Person, Title
267. Phone
269. Reason for service
271. You may be eligible for additional benefits, services and assistance. A representative will contact you directly to discuss eligibility guidelines and application procedures.
273. The information provided on this application is true and accurate to the best of my knowledge. I agree to allow Frederick County Department of Aging staff to complete a phone assessment and home visit/evaluation prior to being considered for Meals on Wheels/Home Delivered Meals services. I agree to allow Frederick County Department of Aging staff to share information with other staff, healthcare providers, partner agencies, and with representatives of agencies currently providing me with services, as appropriate. I agree to notify the Department of Aging if information on my application changes (i.e. emergency contact information). I have read and understand the Meals on Wheels/Home Delivered Meal criteria for service and the contribution policy and I would like to be contacted by a Department of Aging staff person to continue the application process.
275. Print Name*
276. Sign
278. Date*
280. Return to the Frederick County Department of Aging by mail to: Frederick County Department of Aging, Attn: Meals on Wheels, 1440 Taney Ave, Frederick, MD 21702 or FAX to: 301-600-3554 or scan and email to: chock@FrederickCountyMD.gov
Leave This Blank:


282. 1. Receive an email copy of this form.
283. Email address

     This field is not part of the form submission.

284. Submit

* indicates a required field