Healthcare Well-Being Survey Template

Healthcare Well-being Survey Template offers questions about the health and well-being of patients who are 55 years and older. This sample can be edited by the survey maker according to the required details about elderly patients. Some of the question examples of this questionnaire are "Overall, how would you rate the local hospitals in your area?", "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?" et al.



   
 
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?
 
Excellent
 
Good
 
Fair
 
Poor
 
Not sure
 
   
 
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.)
 
   
 
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.
 
   
 
How often does a close friend or relative visit you in your home?
 
Daily
 
Several times a week
 
Weekly
 
Several times a month
 
Once a month or less
 
   
 
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)
 
   
 
Can you get to places out of walking distances:

 
Without help
 
With some help
 
Completely unable to travel unless special arrangements are made
 
Other
 
 
   
 
Can you do your own housework:
 
Without help
 
With some help
 
Completely unable to do any housework
 
Other
 
 
   
 
Can you go shopping for groceries:
 
Without help
 
With some help
 
Completely unable to do any shopping
 
Other
 
 
   
 
Can you prepare your own meals?

 
Without help
 
With some help
 
Completely unable to prepare any meals
 
Other
 
 
   
 
Can you do your own laundry?
 
Without help
 
With some help
 
Completely unable to do any laundry at all
 
Other
 
 
   
 
Can you manage your own money?
 
Without help
 
With some help
 
Completely unable to handle money
 
Other
 
 
   
 
Do you take care of your own appearance, things like combing your hair, shaving, etc?
 
Without help
 
With some help
 
Someone does all these types of things for you
 
Other
 
 
   
 
Do you dress and undress yourself?
 
Without help (pick out clothes, dress/undress self)
 
With some help
 
Does someone dress and undress you
 
   
 
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:
 
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
 
 
   
 
Do you or your spouse experience chronic pain? (either ongoing or recurring pain)
 
Self
 
Spouse
 
Both
 
Neither
 
   
 
If yes, how are you or your spouse currently being treated for chronic pain?
 
No treatment
 
Medication
 
Other
 
 
   
 
Age category:
 
55-59
 
60-64
 
65-69
 
70-74
 
75-79
 
80-84
 
85+
 
   
 
Gender:
 
Male
 
Female
 
   
 
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?
 
Live with spouse only
 
Live with spouse and children
 
Live alone
 
Other
 
 
   
 
Do you own or rent your home?
 
Own
 
Rent
 
Other
 
   
 
Employment status:
 
Retired
 
Employed full time
 
Employed part time
 
   
 
Marital status:
 
Married
 
Divorced
 
Widowed
 
Never been married
 
   
 
Thank you.
 

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