Health Care Well-Being Survey Template

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

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?
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?
Several times a week
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
Can you do your own housework:
Without help
With some help
Completely unable to do any housework
Can you go shopping for groceries:
Without help
With some help
Completely unable to do any shopping
Can you prepare your own meals?

Without help
With some help
Completely unable to prepare any meals
Can you do your own laundry?
Without help
With some help
Completely unable to do any laundry at all
Can you manage your own money?
Without help
With some help
Completely unable to handle money
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
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
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?
No treatment
Age category:
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
Do you own or rent your home?
Employment status:
Employed full time
Employed part time
Marital status:
Never been married
Thank you.

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