Healthy Aging Registration & Nutrition Health

Annual Resident Registration

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* 1. What is today's date?

MM/DD/YYYY

Date

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* 2. At which site do you reside?

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* 3. Resident Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date of Birth (MM/DD/YYYY)

Phone Number

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* 4. Are you over 60?

Yes

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* 5. Are you a spouse of someone 60+? (Under 60 eligibility)

Yes

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* 6. Are you disabled (receiving SSD/SSI)?

Yes

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* 7. If yes, please explain.

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* 8. What is your gender identity?

Male

Female

Two-Spirit

Other (please specify)

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* 9. Is the head of household female?

Yes

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* 10. Please list an emergency contact.

Name

Relationship

Phone number

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* 11. What are your current medical/health conditions? (Mark all that apply)

Diabetes

High cholesterol

High blood pressure

Other (please specify)

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* 12. What is your race/Ethnicity?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Other (please specify)

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* 13. What is your marital status?

Married

Divorced

Never married

Widowed

Separated

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* 14. Including yourself, how many people live in your household?

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* 15. What is your monthly household income?

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* 16. What is your highest education completed?

Less than high school

High school diploma/ GED

Less than bachelor's degree

Bachelor's degree

Master's degree

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* 17. Who do you live with?

Live alone

Live with spouse

Live with extended family

Live with non-family

Live multi-generation

Homeless/in between housing situations.

50% of survey complete.