Health Care and Well Being

This survey is being conducted to gather public opinions of health care needs. In order to complete this survey, please ensure that you are aged 65 or over.

1. In regards to treating age related health problems, how would you rate the hospitals in your area?

2. Which of the following best describes your overall health?

Very Unhealthy - Serious medical history. Very poor diet and no exercise.
Unhealthy - Some serious medical history. Poor diet and little excersise.
Average - Some medical history. No set diet or fitness regime.
Healthy - Little or no medical history. Balanced diet and active lifestyle.
Very Healthy - No previous medical history. Balanced diet and very active lifestyle.

3. Is there someone within your family or friends who can fulfill your needs when you wish to talk or go on outings?

No Social Support - No support is available from both family and friends
Little Social Support - Support is seldom available from both family and friends
Average Social Support - Support is potentially available from family and friends
Good Social Support - Support is available from family and friends
High Social Support - Support is always available from family and friends

4. How often do close friends and relatives visit you?

5. Which of the following best describes your ability to perform everyday tasks

Fully Able - Can perform any task unassisted
Able - Can perform most tasks unassisted
Average - Can perform most tasks unassisted, although assistance is sometimes required
Unable - Regular assistance is required to carry out tasks
Not at all Able - Assistance is relied upong to carry out tasks

6. How easily can you travel long distances?

No Help Needed
Some Help Needed
Cannot Travel Unless Transport is Provided
Other (please specify):

7. Are you able to complete your housework?

Yes, Without Help
Yes, With Some Help
No, Cannot Complete any Housework

8. Are you able to go shopping?

Yes, Without Help
Yes, With Some Help
Unable to Go Shopping

9. Are you able to prepare your own meals?

Yes, Without Help
Yes, With Some Help
Unable to Prepare Meals

10. Are you able to do your laundry?

Yes, Without Help
Yes, With Some Help
Unable to Do Laundry

11. Can you handle your finances?

Yes, Without Help
Yes, With Some Help
Unable to Handle Any Finances

12. Do you take care over your own appearance?

Yes
Yes with Some Assistance
No, Assistance is Required for This

13. Can you dress yourself?

Yes, Unaided
Yes, with Some Assistance
No, Assistance is Required

14. How many different types of medication have you taken over the last 24 hours?

15. How many types of medication, if any, are prescribed by your GP?

16. If you take medication, how do you take it?

Without Assistance - I Take the Correct Medicine at the Correct Time
With Some Assistance - Reminders are Needed to Take the Correct Medicine
Assistance is Required

17. Do you or your partner experience any chronic pain?

Yes, Myself
Yes, My Partner
Yes, Both of Us
Neither

18. If you answered yes, then what sort of treatment is being received for the pain?

19. What is your age category?

20. What is your gender?

Male
Female

21. How many residents live in your household?

22. What are your living arrangements?

Live with Partner
Live with Partner and Children
Live Alone
Other (please specify):

23. Do your rent or own your home?

Rent
Own
Other (please specify):

24. What is your employment status?

Employed Part Time
Employed Full Time
Retired

25. What is your marital status?

Single
Married
Divorced
Widowed