| Possible Problem | Question to Answer | Score for "Yes" Answer (Circle if "yes") |
| Disease | Do you have an illness or condition that makes you change the kind and/or amount of food you eat? | 2 |
| Eating Poorly | Do you eat fewer than 2 meals per day? | 3 |
| Do you eat few fruits, vegetables or milk products? | 2 | |
| Do you have 3 or more drinks of beer, liquor or wine almost every day? | 2 | |
| Tooth Loss/Mouth Pain | Do you have tooth or mouth problems that make it hard for you to eat? | 2 |
| Economic Hardship | Do you sometimes have trouble affording the food you need? | 4 |
| Reduced Social Contact | Do you eat alone most of the time? | 1 |
| Multiple Medications | Do you take 3 or more prescribed or over-the-counter drugs a day? | 1 |
| Involuntary Weight Loss/Gain | Have you lost or gained 10 pounds in the last 6 months without trying? | 2 |
| Needs Assistance In Self Care | Are you sometimes physically not able to shop, cook or feed yourself? | 1 |
| Elder Years > Age 80 | Are you over 80 years old? | 1 |
| TOTAL | ________ |