Other required information: Social Security number to be provided to Meals on Wheels prior to meal start date. What is your need for our services? Check all that apply. Homebound Living alone Unable to cook Unable to shop CLIENT INFORMATION First name: Last name: Street address: Apartment Name Apartment number City: Michigan_City LaPorte Westville State Indiana Zip code: 46360 MC 46350 LP 46391 WV Telephone Number: Type: Home Mobile Email address (if any): Date of birth: Gender: Female Male Ethnicity: White Black Hispanic Asian Marital Status: Married Widowed Single Separated Divorced Do you live alone? Yes No Housemate Name: Are you a veteran? Yes No Do you have a dog? Yes No Do you have a cat? Yes No Emergency Contact Information First name: Last name: Phone number (home) Phone number (mobile) Phone number (work) if any: Relationship to client: Person completing application Who is completing this registration? Client Other First name: Last name: Relationship to client: Phone Number: Necessary Medical Information Primary Care Doctor: Recent illness or accident: Handicaps: Cane Walker Wheelchair Oxygen None Other-Please specify Other: Please specify - None -Please Specify Food Allergies Yes No If yes list foods you are allergic to Potential Medication/Food Interaction? Yes No If yes list medications you take with food interactions Do you have an illness or condition that made you change the kind of food you eat? Yes No Do you eat fewer than 2 meals a day? Yes No Do you eat few fruit and vegetables or milk products? Yes No Do you eat alone most of the time? Yes No Are there times that you do not always have enough money to buy the food you need? Yes No Do you have tooth or mouth problems that make it hard for you to eat? Yes No Do you take 3 or more different prescribed or over the counter drugs a day? Yes No Have you lost or gained 10 pounds in the last 6 months without trying? Yes No Are there times when you are not physically able to shop and/or cook? Yes No Are you interested in the One Meal or Two Meal Option? One Meal Two Meal Frozen Weekend Meals Contribution Determination Info Is your monthly income over $1,470.00? Yes No Housing expense: Do you pay rent or mortgage? Mortage Rent Own my Home If rent or mortgage enter monthly payment Prescription expense: enter average amount of monthly out of pocket How did you hear about us: Television Newspaper Radio Social Media Noticed meal delivery cars I Volunteer Family and/or Friend Doctor Always knew about Meals on Wheels Other: Please specify Please specify: CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit