1. Do you receive Homemaker/Home Health Aide Service?
2. Are you able to get around the house?
3. Are you able to get outside?
4. Are there any other reasons you feel you need a meal delivered to
your home?
5. How long do you think you will need to receive meals?
6. Do you follow a diet given to you by your doctor?
7. Do you know someone who can pick up your meals?
8. Do you lack physical strength?
9. Do you have grossly impaired vision or hearing?
10. Are you bedridden?
11. Are you dependent on life support system?
12. Are you unable to control bodily functions?
13. Do you have a debilitating illness?
14. Are you unable to function with a group of people?
15. Do you have dependence upon addictive drugs?
16. Do you have disruptive behavior in a congregate setting?
17. Is your geographic location remote?
