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. Question 1.

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

Very Poor

Poor

Average

Good

Very Good

2. Question 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. Question 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. Question 4.

How often do close friends and relatives visit you?

Everyday

Several Days a Week

Weekly

Several Times a Month

Once a Month or Less

5. Question 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. Question 6.

How easily can you travel long distances?

No Help Needed

Some Help Needed

Cannot Travel Unless Transport is Provided

Other (please specify):

This is required

Input box for - Other (please specify):

7. Question 7.

Are you able to complete your housework?

Yes, Without Help

Yes, With Some Help

No, Cannot Complete any Housework

8. Question 8.

Are you able to go shopping?

Yes, Without Help

Yes, With Some Help

Unable to Go Shopping

9. Question 9.

Are you able to prepare your own meals?

Yes, Without Help

Yes, With Some Help

Unable to Prepare Meals

10. Question 10.

Are you able to do your laundry?

Yes, Without Help

Yes, With Some Help

Unable to Do Laundry

11. Question 11.

Can you handle your finances?

Yes, Without Help

Yes, With Some Help

Unable to Handle Any Finances

12. Question 12.

Do you take care over your own appearance?

Yes

Yes with Some Assistance

No, Assistance is Required for This

13. Question 13.

Can you dress yourself?

Yes, Unaided

Yes, with Some Assistance

No, Assistance is Required

14. Question 14.

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

15. Question 15.

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

16. Question 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. Question 17.

Do you or your partner experience any chronic pain?

Yes, Myself

Yes, My Partner

Yes, Both of Us

Neither

18. Question 18.

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

19. Question 19.

What is your age category?

65 - 69

70 - 74

75 - 79

80 - 84

85 - 89

90 or Over

20. Question 20.

What is your gender?

Male

Female

21. Question 21.

How many residents live in your household?

22. Question 22.

What are your living arrangements?

Live with Partner

Live with Partner and Children

Live Alone

Other (please specify):

This is required

Input box for - Other (please specify):

23. Question 23.

Do your rent or own your home?

Rent

Own

Other (please specify):

This is required

Input box for - Other (please specify):

24. Question 24.

What is your employment status?

Employed Part Time

Employed Full Time

Retired

25. Question 25.

What is your marital status?

Single

Married

Divorced

Widowed