Health Status Update - Project Angel Heart

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Health Status Update

Project Angel Heart prepares and delivers medically tailored meals, free of charge, for people living with severe illnesses. To requalify for services, the Health Care Provider Authorization and Confirmation & Client Release MUST be completed and signed by the client and their health care provider or social worker.

Applicant Information
First Name*
Last Name*
Middle Initial
Delivery Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County of Residence
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Height (ft & in or cm)
Weight
- lbs
- kg
Applicant Email*
Applicant Phone*
Preferred Language for Communication
Does the Primary Contact Speak English?
- Yes
- No
Primary Contact Name/Relationship
Primary Contact Phone Number
Emergency Contact Name/Relationship (Only list those who are aware of applicant's medical diagnosis)
Emergency Contact Phone Number
Household Information
(Income does not determine eligibility for services, it is collected for grant purposes only)
Monthly Household Income
Source of Income
Number of People in the Household
Additional Meals: Is the applicant a caregiver for children under 18 or another adult in the household?
- Yes
- No
Does the applicant have additional support or a caregiver when needed?
- Yes
- No
Has the applicant experienced food insecurity in the last six months?
- Yes
- No
Primary Diagnosis
Complete this section or securely email an active diagnosis list to refer@projectangelheart.org
Check all ACTIVE diagnoses:
- HIV/AIDS
- Cancer
- End Stage Renal Disease (ESRD)
- Chronic Kidney Disease (please select stage below)
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic Fibrosis
- Other Lung Disease (enter below)
- Heart Failure
- Other Heart Disease (enter below)
- Protein Calorie Malnutrition / Failure to Thrive (must have documented unintentional weight loss or low BMI)
- Parkinson’s
- ALS (Lou Gehrig’s disease)
- Huntington’s Disease
- Multiple Sclerosis (MS)
- Lupus
- Rheumatoid Arthritis (RA)
- High-Risk Pregnancy
- Gestational Diabetes
- Pre-Eclampsia
- Dementia
- TBI
Cancer Type & Stage
Is this diagnosis active?
- Yes
- No
Current cancer treatment
- Chemo
- Surgery
- Radiation
- Immunotherapy
If no current treatment, why? (hospice, treatment pending, on hold)
Chronic Kidney Disease stage
- 1
- 2
- 3
- 4
- 5
Describe Other Lung Disease
Describe Other Heart Disease
Due Date
MM slash DD slash YYYY
Type of Dementia
Date of Injury
Other Concerns/Diagnosis
Other Concerns/Diagnosis
- Diabetes (Type 1)
- Diabetes (Type 2)
- Ambulation Device
- Unintentional Weight Loss
- Poor appetite
- Mouth sores
- Altered taste
- Difficulty chewing/swallowing
- Unintentional weight loss
- Mental Illness/Cognitive Deficits/Substance Abuse
- Partially Blind
- Legally Blind
- Deaf
- Hard of Hearing
Does the applicant have two or more limitations around ADL's or IADL's?
- Yes
- No
Oxygen
- 24/7
- As Needed
How many liters of oxygen?
Describe Ambulation Device
Please include how many lbs, when, and over how long did the weight loss occur
Describe Mental Illness/Cognitive Deficits/Substance Abuse
Diet
Please indicate the requested diet and any other dietary needs due to allergies, side-effects from treatment, religious beliefs, etc. All of our diets are heart healthy. Please note: we cannot accommodate all diet requests.
- Keep my Current Diet
- Renal
- Heart Healthy
- Low Vitamin K/GI-Friendly
- Vegetarian
- Diabetic
- Dairy Free
- Gluten-Friendly
- Unseasoned
- Food Allergies
- Difficulty Chewing/Swallowing
Describe Food Allergies
Nutrition Education & Counseling
Would you like our Registered Dietitian to contact you?*
- Yes
- No
If you have specific questions, please list those here:
If you have questions about diet or side offerings and would like to consult with our registered dietitian, please call 303-407-9439.
Health Care Provider Consent
The medical professional’s signature below:

1. Verifies the applicant named in this application is their patient

2. Confirms that all stated health information on this application is true and accurate
Health Care Provider Consent
(doctor, nurse, licensed clinical social worker, dietitian, etc.)
Name
Title
Phone
Fax
Email
Agency, clinic, hospital, or practice
Signature
Date
MM slash DD slash YYYY
Project Angel Heart Application for Services Consent
The following confirmation/applicant’s consent must be completed, signed, and submitted with the application. By signing this document, I (named below), voluntarily consent for the exchange of my health information between Project Angel Heart and my health care provider, social worker or case manager, for the treatment purposes that qualify me for Project Angel Heart’s meal services. The information shared by my health care provider, social worker or case manager with Project Angel Heart may include HIV/AIDS status, psychiatric and mental health disorders, and substance use. I release my health care provider, social worker or case manager and Project Angel Heart from all liabilities and all claims pertaining to the release and disclosure of such information.
Signature
Date
MM slash DD slash YYYY
Applicant Name
DOB
MM slash DD slash YYYY
If signed by personal representative, list authority of personal representative:
Other Notes/Comments
If you have other non-health information that may be useful to our team, please provide that here.
Other Notes/Comments Entry

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For the non-discrimination statement related to food distribution programs visit:

https://cdhs.colorado.gov/benefits-assistance/food-assistance/food-distribution-programs

The Meals on Wheels America logo, “Together We Can Deliver,” and/or “More Than a Meal” are trademarks of Meals on Wheels America and are used under license.

Denver Office & Kitchen

4950 Washington St
Denver, CO 80216
P 303.830.0202 / F 303.830.1840

Colorado Springs Office

625 W Uintah Street, Suite I
Colorado Springs, CO 80904
P 719.323.0084 or 800.381.5612

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