Rfoodx Nutritional Assessment

Rfoodx Nutritional Assessment

Disclosure Statement

This assessment is for the sole purpose of qualification to receive a medically tailored meal prescription provided under the CalAIM community supports program.

Nutrition Assessment/Consultation Disclosure Statement:*

By completing this assessment, you are consenting to allow Roots Food Group to use your information solely for the purpose of qualifying you to receive a medically tailored meal prescription under the CalAIM community supports program

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Patient's Name*

Best day and time to contact

Delivery instructions (if any)

Is this a request for a refill of Medically Tailored Meals?*

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If yes, please explain how the meals have benefited your health condition:

Gender

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Date of Birth*

CIN Number

Phone number*

Address*

How would you rate your appetite during the last month?*

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Do you have any of the following chronic conditions?*

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Other Chronic Conditions- Please specify for chronic or Disabling Mental/Behavioral Health Disorders***

Do you have any difficulty chewing?*

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If you answered yes, you have difficulty chewing please explain.

Do you have any difficulty swallowing?*

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If you answered yes, you have difficulty swallowing, please explain.

Do you need pureed food ?*

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What did you eat for breakfast yesterday?*

What did you eat for lunch yesterday?*

What did you eat for dinner yesterday?*

What snacks did you eat yesterday?*

What beverages did you drink yesterday?*

Do you have any known food allergies?*

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If yes, to known allergies please explain:

Do you have any cultural/religious food preferences?*

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If other cultural/religious food preferences, please explain:

What has been your average weight over the last year?*

Have you had any weight changes (loss or gain)?*

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If you answered yes, you have had recent weight changes, please explain here.

Height*

Who cooks at home? If a caregiver, please provide name and contact information*

Do you live alone? If yes, please explain problems related to living alone.*

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If yes, please explain problems related to living alone

Do you have care coordination needs (ECM or IHSS)?*

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If yes, please explain and provide contact info:

Have you recently been discharged from the hospital within 12 months?*

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If yes, please explain

If applicable, how many Emergency Room visits have you had in the past year?

If applicable, how many In Patient visits have you had in the past year

How many fruit servings do you eat per day?*

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How many non-starchy vegetables (broccoli, bell peppers, onions, tomatoes) servings do you eat per day?*

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What types of proteins do you eat? (Select all that apply)*

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Do you have a refrigerator with an attached freezer or a separate freezer to store the meals?*

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Do you have a way to reheat the meals?*

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Can you provide PCP information? Please provide name and phone number

Additional Information

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