Meals on Wheels Application

Applicant Information

First Name

M.I.

Last Name

Street Address

Unit/Apt # (if applicable)

Name of Building (if applicable)

City (in King County)

State

Zip Code

Country

Home Phone

Alternate Phone

Date of Birth (MM/DD/YYYY)

Name of other MOW clients/applicants in the household:

(Please note: An application is required for each person applying for the program).

Emergency Contact

First Name

Last Name

Relationship

Phone

Phone Extension

Contact Instructions

Call ApplicantCall Contact	Contact Name
Do you need interpreter services? Yes No Contact Phone Contact Phone Extension	If yes, what language? Is there anything else we should know when contacting you?

Reason for needing Meals on Wheels

Temporarily homebound (convalescing)Homebound some days, not othersLong term homebound

*To be eligible for services, an individual needs to meet the following criteria: Age 60 or older, homebound, unable to prepare meals, difficulty performing activities like bathing, dressing or shopping, and does not have an informal support system. Those under 60 may utilize the program but would be required to pay $8.50 per meal.*

Nutrition Information

	Yes	No	Prefer not to say
Do you have an illness or condition that has changed the way you eat?
Do you eat fewer than 2 meals a day?
Do you eat less than 2-3 servings of fruits, vegetables, or dairy per day?
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?
Do you sometimes run out of money to buy food?
Do you eat alone most of the time?
Do you take 3 or more different medications or supplements per day?
Have you lost or gained 10 pounds in the last 6 months without trying?
is it difficult for you to shop, cook, or feed yourself at times?

Activities of Daily Living

What level of assistance do you need with the following?

	Independent	Minimum	Moderate	Maximum	Prefer not to say
Eating
Walking/Ambulating
Using the Telephone
Dressing
Preparing Meals
Heavy Housework
Bathing
Shopping
Transportation
Toileting
Managing Medications
Transferring out of bed/chair
Managing Money
Chores

Is there anyone in your life who usually helps you out?

YesNo

Do you use an assistance device like a cane, walker, or wheelchair?

YesNo

Applicant Demographic Information

	Yes	No	Prefer not to say
Does your household have children under the age of 18?
Are you a veteran of the U.S. Military?
Is your spouse a veteran of the U.S. Military?
Are you homeless or living in temporary housing?

How did you hear about our program?

Breathing Difficulty	Heart Issues	Liver Disease
Cancer	Hypertension	Multiple Sclerosis
Chronic Illness	Impaired Hearing	Osteoporosis
Chronic Pain	Impaired Speech	Parkinson's Disease
Cognitive Issues	Impaired Vision	Psychological Issues
Diabetes	Kidney Disease	Recent Fall/Injury/Surgery
Gastrointestinal	Limited Physical Mobility	Stroke