|
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. |
| |
|
|
|
Overall, how would you rate the local hospitals in your area? |
| |
|
|
|
|
How would you evaluate your overall health. Would you say you are:
|
| |
|
|
|
|
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? |
| |
|
|
|
|
How often does a close friend or relative visit you in your home? |
| |
|
|
|
|
Which of the following best describes your capacities to perform everyday activities: |
| |
|
|
|
|
Can you get to places out of walking distances:
|
| |
|
|
|
|
Can you do your own housework: |
| |
|
|
|
|
Can you go shopping for groceries:
|
| |
|
|
|
|
Can you prepare your own meals?
|
| |
|
|
|
|
Can you do your own laundry? |
| |
|
|
|
|
Can you manage your own money? |
| |
|
|
|
|
Do you take care of your own appearance, things like combing your hair, shaving, etc? |
| |
|
|
|
|
Do you dress and undress yourself? |
| |
|
|
|
|
| In the past 24 hours, how many different kinds of medication have you taken? | | |
|
|
|
|
| If you have taken medication in the last 24 hours, how many of them have been prescribed by your physician? | | |
|
|
|
|
If you have taken medication in the last 24 hours, do you take your medicine: |
| |
|
|
|
|
Do you or your spouse experience chronic pain? (either ongoing or recurring pain) |
| |
|
|
|
|
If yes, how are you or your spouse currently being treated for chronic pain? |
| |
|
|
|
|
|
|
|
|
| Number of members residing in your household: | | |
|
|
|
|
What are your current living arrangements, in terms of your relation to the people you are living with? |
| |
|
|
|
|
Do you own or rent your home? |
| |
|
|
|
|
|
|
|
|
|