Registration - bistro66web

Last Name:

First Name:

Other Name Used:

Home Phone:

Do you have an answering machine?

Yes No

Cell Phone:

Date of Birth:

Address:

Street:

City:

Zip Code:

Same as Mailing Address:

Street:

City:

Zip Code:

Gender:

Specify Gender:

What race do you identify with?

Specify Race:

Ethnicity:

Income Information:

(effective thru 9/30/2024) Your answer does not affect program eligibility.

Is your income at or below the following guidelines?

Yes No

Single Person – Under $1,215/month or Under $14,580/year

Two Person – Under $1,643/month or Under $19,720/year

Three Person – Under $2,072/month or Under $24,860/year

Four Person – Under $2,500/month or Under $30,000/year

Marital Status:

Household:

I live alone I live with others

Are you 60 years of age or older?

Yes No

Do you have a disability?

Yes No

Do you live with another person who is age 60 or older?

Yes No

Nutrition Check List: Please answer the below questions to find out your level of Nutritional Risk.

I have an illness or condition that made me change the kind of or amount of food I eat.

Yes (Score of 2) No

I eat FEWER than 2 meals per day.

Yes (Score of 3) No

I eat FEW fruits, vegetables, or milk products.

Yes (Score of 1) No

I have 3 or more drinks of beer, liquor, or wine almost every day.

Yes (Score of 1) No

I have tooth or mouth problems that make it hard for me to eat.

Yes (Score of 4) No

I don't always have enough money to buy the food I need.

Yes (Score of 2) No

I eat alone most of the time.

Yes (Score of 1) No

I take 3 or more different prescribed medications each day.

Yes (Score of 2) No

Without wanting to, I have lost or gained 10 pounds in the last 6 months.

Yes (Score of 2) No

I am not always able to physically shop, cook for, or feed myself.

Yes (Score of 2) No

Nutrition Score:

0 - 2 - Good: You’re doing great! Recheck your score in 6 months.

3 - 5 - Moderate Risk: See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizen center or health department can help.

6+ - High Risk: Talk with your doctor, dietician or other qualified health or social services professional about any problems you may have and ask for help to improve your nutritional health. Recheck your score in 6 months.

MALNUTRITION SCREENING TOOL: Please answer the following:

1. Have you lost weight recently without trying? No Unsure Yes

2. If yes, how much weight have you lost?

2-13 pounds 14-23 pounds 24-33 pounds 34 pounds or more Unsure

3. Have you been eating poorly because of a decreased appetite? No Yes

FOOD SECURITY SCREENING: For each of the following statements, please mark if it was “often true”, “sometimes true”, or “never true” within the past 12 months.

1. We (I) worried whether our food would run out before we (I) got money to buy more.

Often True Sometimes True Never True

2. The food that we bought just did not last and we (I) did not have money to get more.

Often True Sometimes True Never True

The Bistro 60 Program offers two ways to receive vouchers. We offer a reloadable personalized voucher card that is REUSABLE or individual paper vouchers that are each ONE TIME USE ONLY, similar to a coupon. Which type of voucher would you like to use when you visit program restaurants?

I am interested in getting a reloadable voucher card.

I would prefer to use the individual paper vouchers.

Please indicate how you prefer to get Bistro 60 Program Updates and Announcements.

MAIL: Please mail me announcements and updates.

EMAIL: I would prefer to get updates and announcements via email.

If selecting email notifications please provide your email address below.

Email Address: