2. 
3. LYON COUNTY HUMAN SERVICES
   620 Lake Avenue Silver Springs, Nevada 89429 ~ Phone: (775) 577-5009 Fax: (775) 577-5093
5. Congregate Meal Survey*

   1. Initial
   2. Follow-up
6. Senior Center*

   1. Dayton
   2. Fernley
   3. Silver Springs
7. Date:*
   Date:

   Date:
9. Your feedback is important to us, the information you provide will help us continue to strengthen our Senior Services programs. All responses are confidential, any identifying information you provide will be kept private and utilized for service enhancement.
11. 1. How would you rate your health?*

    1. Excellent
    2. Very Good
    3. Good
    4. Fair
    5. Poor
12. 2. How often are you sick?*

    1. Seldom
    2. Once every six months
    3. Once every three months
    4. Once a month
    5. Once a week
14. 3. How often does your physical and/or emotional health interfere with your ability to attend to personal business, perform simple household chores, or participate in social activities?*

    1. All of the time
    2. Most times
    3. Sometimes
    4. Rarely
    5. Never
16. 4. How would you rate your diet?*

    1. Excellent
    2. Very Good
    3. Good
    4. Fair
    5. Poor
17. 5. Do you ever feel hungry?*

    1. Yes
    2. No
19. If you answered “yes” to question 5, what would say is the reason(s)?

    1. Can’t afford to purchase enough food
    2. Difficulty preparing meals due to a disability
    3. Don’t have adequate food preparation equipment
    4. Am alone and don’t want to go to the trouble for just myself
    5. Health problems that interfere with eating (dental problems, digestive problems, etc.)

    1. Don’t have a way to get groceries
    2. Don’t know how to cook
    3. Just don’t feel up to cooking
    4. Other
21. Other reason(s):
23. 6. If you answered “yes” to this question previously, and “No” now, what has changed?

    1. Home Delivered Meals
    2. Increased Income
    3. Someone shops for me now

    1. Someone cooks for me now
    2. Learned how to cook
    3. Obtained food preparation equipment

    1. No longer live alone
    2. Generally feel better
    3. Health problems have improved
25. Name of Participant:
    (Optional)
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

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