(Please CHECK One)
(Do You Want To Receive)
- The information you provide will be used to (1) help improve programs for seniors, or (2) find out if you qualify for a program. It may be shared with the Maryland Department of Aging ("MDoA").
- The Commissioners of St. Mary's County through the Department of Aging & Human Services, and MDoA will not voluntarily share any information that identifies you with anyone except people working for them who need the information to perform their jobs. Information that identifies you include your name, address, and telephone number.
- You may refuse to give some or all of the information requested. However, if a program is only for people who meet its qualifications (such as age, income, or health condition) and you do not share the information that show you qualify, then you will not be able to take part in that program. St. Mary's County Department of Aging & Human Services staff can tell you what information is needed to show you qualify for a program.
- You may review a record that identifies you. You may do this to make sure the information is accurate. To review records you must write to St. Mary's County Department of Aging & Human Services, Attention AIM/NAPIS Administrator, P.O. Box 653, Leonardtown, MD 20650 or Maryland Department of Aging, Attention AIM/NAPIS Administrator, 301 West Preston Street, Suite 1007, Baltimore, MD 21201.
The Warning Signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk.
Read the statements below. Circle the number in the "yes" column for those that apply to you or someone you know. For each "yes" answer, score the number in the box.
Total Your Nutritional Score. If it's -
Good! Recheck your nutritional score in 6 months.
You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help.
You are at high nutritional risk. The next time you see your doctor, dietitian or other qualified health or social service professional talk with them about any problems you may have. Ask for help to improve your nutritional health.
Remember that Warning Signs suggest risk, but do not represent a diagnosis of any condition. Turn the page to learn more about the Warnings Signs of poor nutritional health.
These materials are developed and distributed by the
Nutrition Screening Initiative, a project of:
AMERICAN ACADEMY OF FAMILY
THE AMERICAN DIETETIC ASSOCIATION
THE NATIONAL COUNCIL ON THE AGING, INC.
The Nutrition Screening Initiative - 1010 Wisconsin Avenue, NW - Suite 800 - Washington, DC 20007
The Nutrition Screening Initiative is funded in part by a grant from Ross Products Division of Abbott Laboratories, Inc.
The Nutrition Checklist is based on the Warning Signs described below.
Use the word DETERMINE to remind you of the Warning Signs.
Any disease, illness or chronic condition which causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older adults. This can make it hard to remember what, when or if you've eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight and well-being.
Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruit, vegetables, and milk products daily will also cause poor nutritional health. One in five adults skip meals daily. Only 13% of adults eat the minimum amount of fruit and vegetables needed. One in four older adults drink too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day.
TOOTH LOSS/MOUTH PAIN
A health mouth, teeth and gums are needed to eat. Missing, loose or rotten teeth or dentures which don't fit well or cause mouth sores make it hard to eat.
As many as 40% of older Americans have incomes of less than $6,000 per year. Having less-or choosing to spend less-than $25-30 per week for food makes it very hard to get the foods you need to stay healthy.
REDUCED SOCIAL CONTACT
One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being and eating.
Many older Americans must take medicines for health problems. Almost half of older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, nausea, and others. Vitamins or minerals when taken in large doses act like drugs and can cause harm. Alert you doctor to everything you take.
INVOLUNTARY WEIGHT LOSS/GAIN
Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health.
NEEDS ASSISTANT IN SELF CARE
Although most older people are able to eat, one of every five have trouble walking, shopping, buying and cooking foods, especially as they get older.
ELDER YEARS ABOVE AGE 80
Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increase. Checking your nutritional health regularly makes good sense.
RELEASE AND WAIVER OF LIABILITY,
ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
I participate voluntarily in programming and activities sponsored by the St. Mary’s County Department of Aging & Human Services (the “Program”).
Upon the understanding and condition that:
- I acknowledge there are always certain risks involved in participating in the Program. I fully accept and assume all risks in the Program, including those either not known to me or not readily foreseeable at this time—including serious bodily injury or death—and fully accept and assume all responsibility for any losses, costs, and damages I incur as a result of my participation in the Program. I declare I am capable of participating in the Program.
- I recognize the risks of illness and injury inherent in any program and am participating in the Program upon the express agreement and understanding that I hereby forever release, discharge, waive, hold harmless, and covenant not to sue St. Mary’s County Government, its respective departments, administrators, directors, agents, officers, volunteers, employees, independent contractors, boards, commissions, vendors, and other participants (each considered one of the “Releasees” herein) from any and all liability, claims, costs, damages, demands, loses, expenses, and judgments, including attorney’s fees and court costs, caused or alleged to be caused in whole or in part by my participation in the Program, otherwise in connection my participation with the Program, or any illness or injury resulting therefrom.
- I further agree that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (“Agreement”), I, or anyone on my behalf, makes a claim against any of the Releasees in connection with the Program, I will forever indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which may incur as the result of such claim, and hereby agree to indemnify and hold harmless the Releasees from and against all such claims.
- I have read this Agreement, have the authority to execute the Agreement on my own behalf, understand that I have given up substantial rights by signing the Agreement, have signed the Agreement freely, voluntarily, and without any inducement or assurance of any nature, intend it be a complete and unconditional release of all liability to the greatest extent allowed by law, and agree that if any portion of this Agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.
- I hereby execute and deliver this Agreement, in its entirety, to induce the St. Mary’s County Department of Aging & Human Services to permit me to participate in its Program.
- I agree that the Agreement shall be binding upon my heirs, successors, and assigns, and shall survive the end of the Program.
Dept. of Aging and Human Services
41780 Baldridge Street
P.O. Box 653
Leonardtown, Maryland 20650
301-475-4200 ext. 71050