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2023 Annual Newsletter

Get Meals
Volunteer
Programs
Give
About Us
Events
- March for Meals
- Festival of Meals
2023 Annual Newsletter

Home-Delivered Meal Program Referral Form

Eligible applicants must be age 60 or over, homebound, unable to drive/utilize public transportation, leave their home independently, unable to shop and/or prepare a nutritious, and not be attending a day-time program (e.g., dining program, adult day care program, etc.).*

*An individual under the age of 60 may be eligible with an approved waiver (DHS, PACE, Rhody Health, etc.)

Step 1 of 3 - Person Making the Referral

33%

Person Making Referral
Name*
First Last
Phone*
Referred by Email Address*
Client Information
Name*
First Middle Last
Gender*
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Soc. Sec. #
Medicaid #
Home Phone*
Cell Phone
Work Phone
Email*
Preferred Language*
Marital Status*
Race/Ethnicity*
Veteran Status*
Living Situation*

Personal Health History
Difficulties (Please check all that apply)*
- Hearing
- Sight
- Speech
- Mobility
- Other
Medical Conditions (Please check all that apply)*
- Cancer
- Depression
- Diabetes
- Heart Disease
- Lung Disease
- Memory Issue
- Mental Health/Psychological Issue
- Osteoporosis/Arthritis
- Parkinson's
- Renal/Kidney Issue
- Stroke
- Weight Loss/Malnutrition
- Other
Please list any other medical problems.
Why do you need Home Delivered Meals? (Please explain any difficulty with meeting your daily needs)*
Primary Doctor*
Health Insurance Provider*
Doctor Phone
Please answer each question below indicating one of the following responses
Activities Of Daily Living
Please put 0 for None; 1 for Some; 2 for Much; 3 for Cannot
Get in and out of bed/chair
Please enter a number from 0 to 3.
Move about in the home
Please enter a number from 0 to 3.
Dress oneself
Please enter a number from 0 to 3.
Feed oneself
Please enter a number from 0 to 3.
Use the toilet
Please enter a number from 0 to 3.
Tend to personal hygiene
Please enter a number from 0 to 3.
Prepare Nutritional meals
Please enter a number from 0 to 3.
Perform light housekeeping
Please enter a number from 0 to 3.
Perform heavy chores
Please enter a number from 0 to 3.
Manage medications
Manage finances
Please enter a number from 0 to 3.
Use the telephone
Please enter a number from 0 to 3.
Shop for oneself
Please enter a number from 0 to 3.
Drives or utilizes public transportation
Please enter a number from 0 to 3.
Please answer the following questions with Yes or NO
Do you have an illness/condition that may change the kind and or amount of food you eat?
- Yes
- No
Do you eat fewer than 2 meals per day?
- Yes
- No
Do you eat few fruits, vegetables or milk products?
- Yes
- No
Do you have 3 or more alcoholic drinks every day?
- Yes
- No
Do you have teeth/mouth problems that make it difficult for you to eat?
- Yes
- No
I don't always have money to buy the food I need.
- Yes
- No
Do you eat alone most of the time?
- Yes
- No
Do you take 3 or more medications each day?
- Yes
- No
Have you lost or gained 10 pound or more in the past 6 months?
- Yes
- No
I am not always able to shop / cook / feed myself.
- Yes
- No
Do you have difficutly getting out unless transportation is provided?
- Yes
- No
Do you lack outside activity?
- Yes
- No

Emergency Contact
Name*
First Last
Phone*
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Second Emergency Contact
Name*
First Last
Phone*
Relationship*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you have Medicare?
- Yes
- No
Do you have Medicaid?
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.

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Meals on Wheels of Rhode Island
70 Bath St.
Providence RI 02908
(401) 351-6700

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#morethanameal

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Get Meals
Volunteer
Programs
Give
About Us
Events
- March for Meals
- Festival of Meals
2023 Annual Newsletter

Need help? Call us! (401) 351-6700