Nutrition Screening Form

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You must be a member of the BeHealthy or WellSense MassHealth Plans to qualify

Member Name: *

Phone number *

DOB *

Are you a member of one of the following MassHealth plans? *

BeHealthy

Wellsense/Mercy

C3 (community care coorperative)

I am not a member of any of these plans

Within the last 12 months, the food that we bought just didn't last, and we didn't have money to get more *

Often True

Sometimes True

Never True

Within the last 12 months, I (or your household) couldn't afford to eat balanced meals *

Often True

Sometimes True

Never True

In the last 12 months, did you (or any other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food? *

Often

Sometimes

Never

How often did this happen? *

Almost every month

Some months but not every month

Only 1-2 months

Did not happen or Don't know

In the last 12 months, did you every eat less than you felt you should because there wasn’t enough money for food? *

Yes

In the last 12 months, were you ever hungry and didn’t eat because there wasn’t enough money for food? *

Yes

Do you have a mental health condition or substance use disorder? *

None

Anxiety (for example, Social Anxiety disorder, separation anxiety disorder, panic disorder, medication-induced anxiety disorder, general anxiety disorder)

Attention Deficit Disorder (ADHD)

Depression

Hoarding disorder

Serious Emotional Disturbance (for example Avoidant/restrictive food intake disorder, eating disorders, obsessive compulsive disorder, childhood schizophrenia

Serious Mental Illness (for example, Schizophrenia, Bipolar disorder)

Substance Use Disorder (for example Opiod Use Disorder, Alcohol use disorder, Phencyclidine Use Disorder, Cannabis Use Disorder

Other:

Required

Do you have a medical condition that is serious, ongoing or disabling? *

None

Autoimmune Conditions (for example rheumatoid arthritis, lupus)

Cancer (for example breast cancer, lymphoma, leukemia, melanoma, kidney cancer, lung cancer, prostate cancer, colorectal cancer, bladder cancer)

Cardiovascular disease/Heart disease (for example high blood pressure, high cholesterol, heart disease, history of heart attack, high cholesterol, heart failure)

Developmental Disabilities (for example Autism, Cerebral palsy)

Diabetes ( Prediabetes, insulin dependent diabetes, Type 2 diabetes, Type 1 diabetes)

Disabilities (for example vision impairment, hearing impairment, locomotor disability)

Gastrointestinal Conditions (for example Crohn’s, Celiac Disease, Irritable bowel syndrome, Peptic Ulcer Disease

HIV/AIDS

Blood related conditions (for example anemia, Sickle cell disease)

Kidney disease/Renal disease (for example End stage kidney disease, chronic kidney disease)

Liver disease (for example hepatitis, cirrhosis)

Lung Disease/Respiratory condition/Pulmonary Disease (for example asthma, COPD, chronic bronchitits, pulmonary fibrosis)

Metabolic Conditions (for example malnutrition, obesity)

Neurologic Conditions (for example neuropathy, stroke, Parkinson’s disease, Alzheimer’s disease, Amyotrophic Lateral Sclerosis (ALS), dementia, epilepsy, Multiple Sclerosis)

Other

Required

Do your mental health condition(s) and/or your physical health condition(s) require treatment or care in order to improve your current condition,or prevent it from getting worse? (for example, do you see a doctor for this condition, take medication, have bloodwork done etc) *

Yes

Do you need help performing any of the following activities? Please mark the ones you do have difficulty with
*

Bathing

Dressing

Eating

Using the Bathroom

Walking or moving yourself from a bed to a wheel chair ( If applicable)

Housework

Managing Personal Finances

Managing Medications

Phone Use

Shopping

Transportation (do not drive independently, need assistance navigating public transportation or arranging rides)

Required

Are you or someone in your household able to prepare meals?
*

Yes

Are you pregnant or were you pregnant in the last 2 months?

Yes

Clear selection

Were you pregnant in the last 3- 12 months?

Yes

Clear selection

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