Nutrition Assessment Form

One step to better support

Get started today - Complete the form below

Thanks to the generous support of donors and partners like the Area Agency on Aging, Silver Key can offer a variety of programs to support you. To make sure we’re giving you the best possible help, we ask each participant to complete a short assessment. This simple step lets us confirm eligibility, match you with the right level of support, and sometimes even connect you with extra resources to make life a little easier and more enjoyable. The assessment is needed for Home Delivered Meals, Health & Wellness, and Handyperson services.

As part of our funding requirements, we complete an assessment for each participant. This assessment helps confirm eligibility, determine the level of assistance we can provide, and in some cases, identify additional resources to enhance your quality of life.

Home Delivered Meals, Case Management and Chore Services Assessment - PPAAA

Silver Key receives funding and donations from a variety of sources, including the Area Agency on Aging, to support many of our programs. As part of our funding requirements, we complete an assessment for each participant. This assessment helps confirm eligibility, determine the level of assistance we can provide, and in some cases, identify additional resources to enhance your quality of life. This assessment applies to Home Delivered Meals, Health & Wellness, and Handyperson services.
Which service(s) or program(s) are you interested in for today's assessment?
Name
MM slash DD slash YYYY
Which programs are you currently receiving at Silver Key? *Silver Key Question
Are you living outside of the city in the following locations (see options below) *Silver Key Question

Eligibility Section

Meal eligibility for those under age 60, you are eligible if you answer Yes to the following:

Self-declared spouse of p articipating individual 60+
Volunteer for the meal program
Individuals with disabilities who lives with an active participant aged 60+

Demographics Section

Do you live alone or with others?

Meal eligibility for those under age 60, you are eligible if you answer Yes to the following:

1 person $1,304 mo / $15,650 yr
2 people $1,763 mo / $21,150 yr
How many people in your household are under 18 years old? *Silver Key Question
Do you take care of a disabled person (other than yourself)? *Silver Key Question
Do you have a pet? If so what do you have? [sometimes Silver Key receives temporary grants to help provide pet assistance] *Silver Key Question
Are you a Veteran or the spouse of a Veteran? *Silver Key Question

Because you are a veteran [or spouse of a veteran], would you be interested in:

RECEIVING Vet-to-Vet Companionship/peer support? [Can include Vet spouses]
PROVIDING Vet-to-Vet or Senior Companionship/peer support? [Can include Vet spouses]
RECEIVING Senior Companionship/peer support?

Communication Section

If your primary language is not English, mark Yes below

Service Access and Support Section

Can you access this serv Advantage Benefits/PACE? ice through another benefit or program? i.e. Medicaid, HCBS or Medicare
MEALS - Do you have reliable outside support from family, friends, or a caregiver for Meals? Does your support help with food access or meal preparation?
CHORES/HANDYPERSON - Do you have reliable outside support from family, friends, or a caregiver for home safety and maintenance tasks?
MEALS - Can you part icipate in meals at a Congregate Site or Connection's Cafe?
Are you isolated from community resources? i.e. Stores, banks, health services, senior center activities. Select "Yes" if a You have a health conditi resources; (3) You have fin community resources; (4) in your community due to ny of the following statements are true: (1) You live in a remote area; (2) on or disability that makes it difficult for you to access community ancial or technology challenges that make it difficult for you to access You cannot drive or use public transportation; (5) You do not feel welcome cultural or language barriers.
Do you receive Meals from another agency?

Nutrition Risk Score Questions

Do you have an illness or condition that has made you change the kind and/or amount of food you eat?
Do you eat fewer than 2 meals per day?
Do you eat few fruits, vegetables, or milk products?
Do you have 3 or more drinks of beer, liquor, or wine almost every day?
Do you have tooth or mouth problems that make it hard for you to eat?
Are there times you do not have enough money to buy the food you need?
Do you eat alone most of the time?
Do you take 3 or more different prescribed or over the counter drugs a day?
Without wanting to, have you lost or gained 10 lbs in the last 6 months?
Are there times you're physically unable to shop, cook and/or feed yourself?
Enter total Nutrition Screening Score below (total nutrition score for Nutrition rows 1-10). If member is at high nutrition risk, speak with a qualified health or social service professional about your nutritional health. ***Providers - if the member is at high nutrition risk (6 or more), please make an Empowor referral to the Silver Key Dietitian.

Nutrition Counseling - *Meals Eligibility Question

Are you interested in Nutrition Counseling?

The Hunger Vital Sign - *Meals Eligibility Question

For each of the following statements please tell us which one is "often true", "sometimes true" or "never true", for the past 12 months: (If you answered often true or sometimes true to either or both questions below, you are at risk for food insecurity. For food and nutrition resources call Silver Key at 719-884-2300 or the confidential Food Resource Hotline toll free at 855-855-4626.
I worried whether my food would run out before I got money to buy more.
The food that I bought just didn't last and I didn't have money to get more.

Substance Use Questions

***Not used for Meals Eligibility*** - Medicaid only
Are you currently struggling with misuse/overuse of drugs or alcohol (both prescription or non-prescription)
Do you have a history of misuse/overuse of drugs or alcohol (both prescription or non-prescription)
Do you want information on risks associated with substance use, to include communicable disease testing support or organizations who provide support for those struggling with substance abuse? [If Yes, Assessor, send resource -- Resource Navigators > Document > General > Community Resources > Substance Use > Substance Use Resources.docx]
Do you have any past or present criminal charges? An answer of "yes" will not have an impact for services.

Activities of Daily Living (ADLs)

Bathing/Showering
Dressing: Putting on and taking off clothing and shoes
Using the bathroom: Getting to and on/off toilet, managing clothing and wiping
Transferring in/out of bed/chair: Getting in and out of sitting or lying positions
Walking/getting around the house
Eating/Drinking

Instrumental Activities of Daily Living (IADLs)

Meal preparation: Planning, making and cleaning up meals
Shopping: Selecting and paying for food, household supplies, and other items
Money Management: Budgeting, using cards and bank accounts, paying bills
Using a Telephone: Making and receiving calls
Light Housework: Tidying up, sweeping, vacuuming, mopping, cleaning kitchen/bathroom surfaces, taking out garbage
Transportation: Driving, walking, or using other forms of available transportation, like buses
Does anyone assist you with ADL or IADL activities?

Nutrition and a Healthy Diet

Are you interested in learning about nutrition and a healthy diet (through automated text messages)?

If yes, you can enroll in Text2LiveHealthy, a nutrition education program deliverec to you via text message. Text the word FRUIT to 97699. Text HELP for information. To opt out, text STOP to 97699. Messaging and data rates may apply. For Privacy Policy and Terms and Conditions, visit: https://coloradosph.cuanschultz.edu/text2livehealthy

Care Plan - Case Managers will create a Care Plan with the member *for Health and Wellness only.

Disclosures and Waivers
Do you consent to telehealth services (verbally or otherwise)? [Silver Key Question]
Does someone have medical or financial authority to make decisions on your behalf? [Silver Key Question]

If yes, please provide the information of the person who has medical and financial authority:
Name
MM slash DD slash YYYY

Thank you for completing this assessment. While assessments are typically completed once a year, they may be required often based on your individual circumstances or program requirements.

If you submitted this assessment electronically, you can expect to hear from us within 24-48 hours. If you do not receive a response within that time frame, please call our Silver Line at 719-884-2300 to check on your status. When calling, be sure to let them know whether you are applying for Meals on Wheels or another type of assistance.