YouThe Client
MaleFemaleGender nonbinary/Genderqueer/Gender nonconformingTransgenderDecline to State
HomeCell
YesNoDecline to state
YesNo
Asian American/AsianBlack/African American/AfricanHispanic/Latino/Latina/LatinxMiddle EasternNative American/American Indian/IndigenousPacific IslanderWhite/CaucasianMulti-racial/Multi-ethnicDecline to StateIdentity not listed here
YesNo
YesNo
VeteranNot a VeteranSpouse of a VeteranDon't Know or N/A
RegularHeart HealthyDiabeticRenalVegetarianPre-CutMechanically SoftenedPureed
EggsNutsCitrusCoconutChileDark GreensFishPork
012345
012345
012345
012345
012345
MilkNo Milk
01234567
Not ApplicableMondayTuesdayWednesdayThursdayFriday
Add breakfastAdd dinner
YesNo
YesNo
YesNo
Do you understand that you or another person MUST be home to receive delivery between the hours of 10:00am - 2:00pm. Meals on Wheels will not leave a meal unattended at your door. Failure to be home without prior notification may result in additional fees and/or removal from the program.
Yes, I understand
Do you understand that Meals on Wheels may call a Wellness Check with APD on your behalf if if we are unable to reach you or your emergency contact for a missed delivery?
Yes, I understand
Do you understand that Meals on Wheels New Mexico has limited options available for menu exclusion requests and that no guarantee can be made that meals will be completely free of allergens. Additionally, exclusion of certain foods from your menu may result in receiving multiples of the same side dish or vegetable per day/week and/or may result in receiving an “alternate” main dish (chicken or beef patty) instead of the planned main entrée for the day.
Yes, I understand
YesNo
YesNo
01 time2-3 times4 or more times
01 time2-3 times4 or more times
NoYes
NeverRarelySometimesOften