*02AG002E-001E*
OKLAHOMADEPARTMENT OF HUMAN SERVICES
Older Americans Act Assessment, Part I
Initial date of contact
Assessment *1Q2A1*
Reassessment *1Q2A3*
Date
Source of referral to this office:
Name Agency Agency case number
Person providing consumer assessment data:
Name Relationship Phone
Consumer information:
Full name Social Security number Address Date of birth Age Home phone County
Gender
Male Female
Special eligibility:
Person is not age 60 or over.
Spouse Handicap/disabled, lives with participant Meal volunteer Handicap/disabled, lives in elder housing
Race:
White/Caucasian Black/African American Hispanic Asian or Pacific Islander Native American or Alaskan
Residence:
Check only if not the private residence.
Nursing home
*1Q7A3*
Other
*1Q7A4*
Does consumer live alone?
Yes
*1Q8A2*
No If no, specify with whom:
Poverty level:
Above
*1Q12A1*
Below
*1Q12A2*
Refused
*1Q12A4*
Monthly income: One person Two persons Description of consumer's current situation:
OKDHS issued 11-10-2006 02AG002E (AG-2-A, Part I) Page 1 of 5 02AG002E (AG-2-A, Part I) Older Americans Act Assessment
Primary doctor name
City
Current medical condition/illness
Emergency contact(s) outside the home and not in the same household:
Name
Relationship
Phone
OKDHS makes no distinction on the grounds of race, sex, religion, color, or national origin in the provision of services in accordance with the Civil Rights Act of 1964.
Consumer signature
Date Interviewer name (print) Agency Phone Date
Do you participate in another program like this?
Yes NoIf yes, where? Spouse's full name
Donation system explained:
Yes No
Referrals to:
Mo/Day/Year
Services referred for
Agencyreferred to
Contact name
Case number
Page 2 of 5 OKDHS issued 11-10-2006
Older Americans Act Assessment 02AG002E (AG-2-A, Part I)
Release of to release Agency or its representative
information contained herein to the following:
Agency or individual
Consumer signature and date
Agency or Individual
Consumer signature and date
Agency or individual
Consumer signature and date
Agency or individual
Consumer signature and date
This grant of authority shall last to the next review.
Directions to consumer's location: Additional comments:
Provision for Title III-B home repair: The home owner must approve any Title III home repairs.
Consumer
owns rents home
OKDHS issued 11-10-2006 Page 3 of 5
02AG002E (AG-2-A, Part I) Older Americans Act Assessment
Page 4 of 5 OKDHS issued 11-10-2006
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 and circle the 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.
• What illness?
•How does this affect your diet or ability to eat?
2
*7Q1A1*
I eat fewer than two meals per day.
•How many meals per day?
•How many snacks per day?
•If under two, what is the problem?
3
*7Q2A1*
I eat few fruits, vegetables, or milk products.
•How many fruits per week? Which ones?
•How many vegetables per week? Which ones?
•How many milk products per week? Which ones?
2
*7Q3A1*
I have three or more drinks of beer, liquor, or wine almost every day.
• Which ones?
2
*7Q4A1*
I have tooth or mouth problems that make it hard for me to eat.
•What type of problems?
•How do you modify your diet to accommodate this?
2
*7Q5A1*
I don't always have enough money to buy the food I need.
•How often do you feel you cannot afford groceries?
•What limits you?
4
*7Q6A1*
I eat alone most of the time.
•Do you prefer to eat alone? What about congregate settings?
•Eat fast food? Interested in cooking? Interested in shopping?
1
*7Q7A1*
I take three or more different prescribed (Rx) or over-the-counter (OTC) drugs a day.
•Which one: OTC or Rx? What are they used for?
1
*7Q8A1*
Without wanting to, I have lost or gained ten pounds in the last six months.
•Which one: lost/gained
•Do you know why this happened?
2
*7Q9A1*
I am not always physically able to shop, cook, or feed myself.
•Which one: shop/feed/cook? Why?
•Who provides the service for you?
2
*7Q10A1*
TOTAL
Total nutritional score:
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.
Older Americans Act Assessment 02AG002E (AG-2-A, Part I)
Nutrition Checklist is based on the warning signs described below:
Disease - Any disease, illness, or chronic condition that causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older adults. This can make it hard to remember what, when, or if you've eaten.Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight, and well-being.
Eating poorly - Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruit, vegetables, and milk products daily will also cause poor nutritional health. One in five adults skips mealsdaily. Only 13% of adults eat the minimum amount of fruit and vegetables needed. One in four older adults drinks too much alcohol. Many health problems becomeworse if you drink more than one or two alcoholic beverages per day.
Tooth loss or mouth pain - A healthy mouth, teeth, and gums are needed to eat. Missing, loose, or rotten teeth, or dentures that don't fit well or cause mouth soresmake it hard to eat.
Economic hardship - As many as 40% of older Americans have incomes of less than $6,000 per year. Having less--or choosing to spend less--than $25 to $30 perweek for food makes it very hard to get the foods you need to stay healthy.
Reduced social contact - One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being, and eating.
Multiple medicines - Many older Americans must take medicines for health problems. Almost half of older Americans take multiple medicines daily. Growingold may change the way you respond to drugs. The more medicines you take, the greater the chance for side effects, such as increased or decreased appetite,change in taste, constipation, weakness, drowsiness, diarrhea, and nausea.Vitamins or minerals when taken in large doses act like drugs and can cause harm.Alert your doctor to everything you take.
Involuntary weight loss/gain - Losing or gaining weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health.
Needs assistance in self care - Most older people are able to eat, but one of every five has trouble walking, shopping, and buying and cooking food, as they get older.
Elder years above age 80 - Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increases. Checking yournutritional health regularly makes good sense.
Portions of these materials developed and distributed by the Nutrition Screening Initiative, a project of American Academy of Family Physicians, the American Dietetic Association andNational Council on Aging, Inc. and The Nutrition Screening Initiative, 2626 Pennsylvania Avenue, NW, Suite 301, Washington, DC 20037. The Nutrition Screening Initiative is funded in part by a grant from Ross Laboratories, a division of Abbot Laboratories.
OKDHS issued 11-10-2006 Page 5 of 5
