NAPIS Registration Form February 2019 English



Welcome! We’re glad you’re here. Would you help us by telling us a bit about you? Services are funded in part by the Older Americans Act, a federal program since 1965. Annually we report demographics of participants. All information is confidential - we do not report personal information - only age, gender, race, zip code, poverty, etc.Section I – Tell us about youLast: FORMTEXT ?????First: FORMTEXT ?????Middle initial: FORMTEXT ???Phone: FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX FemaleDate of birth: FORMTEXT ?????Number in household: FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 or moreStreet address: FORMTEXT ?????City: FORMTEXT ?????ZIP: FORMTEXT ?????Mailing address: FORMTEXT ?????City: FORMTEXT ?????ZIP: FORMTEXT ?????Monthly household incomeRace (select all that apply)Number in household1: FORMCHECKBOX $1,041 or below FORMCHECKBOX $1,042 or above FORMCHECKBOX American Indian/2: FORMCHECKBOX $1,409 or below FORMCHECKBOX $1,410 or aboveAlaska Native3: FORMCHECKBOX $1,778 or below FORMCHECKBOX $1,779 or above FORMCHECKBOX Asian 4: FORMCHECKBOX $2,146 or below FORMCHECKBOX $2,147 or above FORMCHECKBOX Black/African American FORMCHECKBOX Native Hawaiian/Other Pacific Islander FORMCHECKBOX WhiteEthnicity FORMCHECKBOX Unknown - some other race FORMCHECKBOX Hispanic/Latino FORMCHECKBOX Not Hispanic/LatinoSection 2 – In case of an emergency - please contact (Optional information)Contact name 1: FORMTEXT ?????Phone: FORMTEXT ????? FORMCHECKBOX Child FORMCHECKBOX Spouse FORMCHECKBOX Friend FORMCHECKBOX Grandchild FORMCHECKBOX Other family FORMCHECKBOX Neighbor FORMCHECKBOX Not relatedContact name 2: FORMTEXT ?????Phone: FORMTEXT ????? FORMCHECKBOX Child FORMCHECKBOX Spouse FORMCHECKBOX Friend FORMCHECKBOX Grandchild FORMCHECKBOX Other family FORMCHECKBOX Neighbor FORMCHECKBOX Not relatedComplete Sections 3 and 4 if you participate in a nutrition or in-home serviceSection 3 – Nutritional data (Please check all that apply) FORMCHECKBOX I have an illness/condition and had to change the kind and/or amount of food I eat. FORMCHECKBOX I eat fewer than 2 meals per day. FORMCHECKBOX I eat few fruits, vegetables or milk products. FORMCHECKBOX I have 3 or more drinks of beer, liquor or wine almost every day. FORMCHECKBOX I have tooth or mouth problems that make it hard for me to eat. FORMCHECKBOX I don’t always have enough money to buy the food I need. FORMCHECKBOX I eat alone most of the time. FORMCHECKBOX I take 3 or more prescribed or over-the-counter drugs a day. FORMCHECKBOX Without wanting to, I have lost or gained 10 pounds in the last six months. FORMCHECKBOX I am not always physically able to shop, cook and/or feed myself.Section 4 – Activities of daily living* and instrumental activities of daily livingPlease mark I - Independent A - Assistance needed D - Dependent on helper FORMDROPDOWN Bathing* FORMDROPDOWN Behavior* FORMDROPDOWN Dressing* FORMDROPDOWN Eating* FORMDROPDOWN Elimination/Toileting* FORMDROPDOWN Mobility/Walking* FORMDROPDOWN Personal Hygiene/Grooming* FORMDROPDOWN Transferring* FORMDROPDOWN Food Preparation FORMDROPDOWN Heavy Housework FORMDROPDOWN Housekeeping FORMDROPDOWN Managing Finances FORMDROPDOWN Medication Management FORMDROPDOWN Shopping FORMDROPDOWN Taking Medication FORMDROPDOWN Using Telephones FORMDROPDOWN Using TransportationDo you have information or comments you’d like to share? FORMTEXT ????? ................
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