CASEWV Commission on Aging Services ApplicationPlease answer all questions below. If you have issues please contact us at Service You Are Interested In * Name * First Name Last Name Email * Middle Initial Other Name Date of Birth * MM DD YYYY Gender * Male Female Phone Number * (###) ### #### Emergency Contact * Emergency Contact Phone Number * (###) ### #### Living Arrangement * Lives Alone Lives with a Friend(s)(non-relative) Lives with Child/Children Lives with other family member Lives with paid help Lives with Significant other Lives with spouse and children Lives with spouse and others Lives with spouse only Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country What is your ethnic race(s)? * American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Hispanic White Non-Hispanic (non-minority) Other What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Are you a veteran? * Yes No Do you need hands on assistance with transportation? Yes No Marital Status * Divorced Married Separated Single Widowed Do you speak English? Yes No Do you have any language limitations? No limitations Reading/Writing Limited Reading only Does not read What is your primary method of transportation? * Drives own car Caregiver Family/Friends Public Transportation Senior Center Transportation Other None Nutrition Information I have an illness or condition that made me change the kind of food I eat * Yes No I eat fewer than 2 meals a day. Yes No I eat few fruits and vegetables, or milk products. * Yes No I have 3 or more drinks of beer, liquor, or wine almost every day. * Yes No I have tooth or mouth problems that make it hard for me to eat. Yes No I don't always have enough money to buy the food I need. * Yes No I eat alone most of the time. * Yes No I take 3 or more different prescribed or over-the-counter drugs a day. * Yes No I am not always physically able to shop, cook, and/or feed myself. * Yes No Please select your ability to complete each of the tasks below. Bathing * No Assistance Some Assistance Much Assistance Unable to Perform Dressing No Assistance Some Assistance Much Assistance Unable to Perform Eating * No Assistance Some Assistance Much Assistance Unable to Perform Walking in Home * No Assistance Some Assistance Much Assistance Unable to Perform Transfering * No Assistance Some Assistance Much Assistance Unable to Perform Eating * No Assistance Some Assistance Much Assistance Unable to Perform Toileting * No Assistance Some Assistance Much Assistance Unable to Perform Transportation * No Assistance Some Assistance Much Assistance Unable to Perform Meal Preparation * No Assistance Some Assistance Much Assistance Unable to Perform Shopping * No Assistance Some Assistance Much Assistance Unable to Perform Light Housekeeping * No Assistance Some Assistance Much Assistance Unable to Perform Manage Money * No Assistance Some Assistance Much Assistance Unable to Perform Telephone * No Assistance Some Assistance Much Assistance Unable to Perform Manage Medication * No Assistance Some Assistance Much Assistance Unable to Perform Thank you! Someone from the CASEWV Commission on Aging will be in contact with you soon.
