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Health Care Well-Being Survey - Template

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1. Survey evaluation of the health and well being of persons 55 years and older.

Q1. We are conducting a brief public opinion survey of persons 55 years of age and older regarding health care needs. This survey is to be completed by someone who falls into that age category.

Q2. Overall, how would you rate the local hospitals in your area?

ExcellentGoodFairPoorNot sure

Q3. How would you evaluate your overall health. Would you say you are:

In good physical health. (No significant illnesses or disabilities. Only routine medical care such as annual checkups required.)Mildly physically impaired. (You have only minor illnesses and/or disabilities which might benefit from medical treatment or corrective measures.)Moderately physically impaired. (You have one or more diseases or disabilities which are either painful or which require substantial medical treatment.) Severely physically impaired. (You have one or more illnesses or disabilities which are either severely painful or life threatening, or which require extensive medical treatment.) Totally physically impaired. (Confined to bed and requiring full-time medical assistance or nursing care to maintain vital bodily functions.)

Q4. What about the amount of social support you receive from your family, friends, etc? When you have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs?

High degree of social support. (Much support is either given or is available, if needed, from family and friends.)Above average degree of social support. (Given or potentially available from family and friends.)Average degree of social support from family and friends is given or potentially available.Below average degree of social support. (While some support is available, it's not consistently available)No support or potential support is available from either family or friends.

Q5. How often does a close friend or relative visit you in your home?

DailySeveral times a weekWeeklySeveral times a monthOnce a month or less

Q6. Which of the following best describes your capacities to perform everyday activities:

You can perform all physical activities of daily living without assistance. (Excellent capacity)You can perform all physical activities without assistance but may need some help with the heavy work such as laundry and housekeeping. (Good capacity)You regularly require help with certain physical activities and/or heavy work but can get through any single day without help. (Moderate capacity)You need help each day but not necessarily throughout the day or night. (Severely impaired capacity)You need help throughout the day and/or night to carry out the activities of daily living. (Completely impaired capacity)

Q7. Can you get to places out of walking distances:

Without helpWith some helpCompletely unable to travel unless special arrangements are made

Other (please specify)

Q8. Can you do your own housework:

Without helpWith some helpCompletely unable to do any housework

Other (please specify)

Q9. Can you go shopping for groceries:

Without helpWith some helpCompletely unable to do any shopping

Other (please specify)

Q10. Can you prepare your own meals?

Without helpWith some helpCompletely unable to prepare any meals

Other (please specify)

Q11. Can you do your own laundry?

Without helpWith some helpCompletely unable to do any laundry at all

Other (please specify)

Q12. Do you take care of your own appearance, things like combing your hair, shaving, etc?

Without helpWith some helpSomeone does all these types of things for you

Other (please specify)

Q13. Do you dress and undress yourself?

Without help (pick out clothes, dress/undress self)With some help

Q14. In the past 24 hours, how many different kinds of medication have you taken?

Q15. If you have taken medication in the last 24 hours, how many of them have been prescribed by your physician?

Q16. If you have taken medication in the last 24 hours, do you take your medicine:

Without help (in the right doses at the right time)With some help (take medicine if someone prepares it for you and/or reminds you to take it)Completely unable to take your own medicines

Other (please specify)

Q17. Do you or your spouse experience chronic pain? (either ongoing or recurring pain)

SelfSpouseBothNeither

Q18. If yes, how are you or your spouse currently being treated for chronic pain?

No treatmentMedication

Other (please specify)

Q19. Age category:

55-5960-6465-6970-7475-7980-8485+

Q20. Gender:

MaleFemale

Q21. Number of members residing in your household:

Q22. What are your current living arrangements, in terms of your relation to the people you are living with?

Live with spouse onlyLive with spouse and childrenLive alone

Other (please specify)

Q23. Do you own or rent your home?

OwnRent

Other (please specify)

Q24. Employment status:

RetiredEmployed full timeEmployed part time

Q25. Marital status:

MarriedDivorcedWidowedNever been married

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Health Care Well-Being Survey - Template