Nutrition for All Counseling Screening Form
Interfaith Outreach is partnering with Nutrition For All to provide free nutrition counseling sessions to guests of the food shelf. Participants will be able to receive 6 one-on-one counseling sessions with a registered dietitian. Appointments will be available online throughout the week or in-person on Wednesdays at Interfaith Outreach.

Please answer these questions to the best of your ability to determine if you qualify for nutrition counseling with Nutrition for All. Once we receive your responses, we will reach out to you via email within 48 hours.

All answers to your questions are completely private and will only be shared with your nutrition provider.

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What is your full name? *
What is your email? *
What is your phone number? *
Are you or is the person you're filling this form out for 18 years or older? *
What is your full date of birth? *
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What is your gender? (male, female, nonbinary, other, etc.) *
Intake Questions
Were you referred to this program by a case manager at Interfaith Outreach? If so, who? *
What food shelf do you currently utilize? *
Have you utilized this food shelf at least once within the past year? *
What is your preferred language? *
Have you been to the doctor for a health check-up/screening in the past 12 months? *
Do you have online access to the doctor's notes from your most recent visit? *
Health History Questions
Do you feel as though most of your body weight is found around your waist? *
During your most recent doctor’s visit, were you told you had high cholesterol levels and/or do you currently take medication for high cholesterol? *
During your most recent doctor’s visit, were you told that you had high blood pressure and/or do you currently take medication for high blood pressure? *
During your most recent doctor’s visit, were you told that you had high blood sugar or prediabetes and/or do you currently take medication for high blood sugar or prediabetes? *
Have you been diagnosed with type 2 diabetes? *
Food Security Questions
These next questions are about the food eaten in your household in the last 12 months of last year and whether you were able to afford the food you need.
The first statement is, “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? *
“(I/we) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? *
Note: balanced meals include all the types of foods that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit, and some type of protein like meat, fish, cheese, or eggs.
In the last 12 months, did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food? *
How often did this happen in the past 12 months—almost every month, some months but not every month, or in only 1 or 2 months? *
In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? *
In the last 12 months, were you every hungry but didn't eat because there wasn't enough money for food? *
Eating Pattern Questions
Please answer these questions to the best of your ability.
Do you worry that you have lost control over how much you eat? *
Do you make yourself sick when you feel uncomfortably full? *
Do you currently suffer with or have you ever suffered in the past with an eating disorder? *
Do you ever eat in secret? *
Readiness for Change Questions
Please answer these questions on a scale from 0-10, with 0 being ‘not at all’ and 10 being ‘very’

 

How important is it to improve your health through dietary changes? *
Not at all
Very
How ready are you to make the changes necessary to improve your diet? *
Not at all
Very
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