Senior Center Survey
1
. Why do you come to the Senior Center? Please rate each reason that applies and add your own.
Least
Middle
Most
Social interaction
*
Why do you come to the Senior Center? Please rate each reason that applies and add your own. Social interaction Least
Social interaction
Social interaction Middle
Social interaction
Social interaction Most
Exercise
Exercise Least
Exercise
Exercise Middle
Exercise
Exercise Most
Meals
Meals Least
Meals
Meals Middle
Meals
Meals Most
Education
Education Least
Education
Education Middle
Education
Education Most
Other
Other Least
Other
Other Middle
Other
Other Most
2
. How frequently do you come to the Senior Center?
How frequently do you come to the Senior Center?
2 to 3 times a week
2 to 3 times a month
2 to 3 times a year
Other (please specify)
3
. Before coming to the Senior Center, did you often feel lonely?
Before coming to the Senior Center, did you often feel lonely?
Yes
No
No Different
Comment
4
. Since coming to the Senior Center, do you feel healthier?
Since coming to the Senior Center, do you feel healthier?
Yes
No
No Different
Comment
5
. When you eat lunch at the senior Center, is this your main meal of the day?
When you eat lunch at the senior Center, is this your main meal of the day?
Yes
No
Comment
6
. How often do you eat lunch at the Senior Center?
How often do you eat lunch at the Senior Center?
2 to 3 times a week
2 to 3 times a month
2 to 3 times a year
I do not eat lunch at the senior center
Other (please specify)
7
. How often do you cook at home?
How often do you cook at home?
Always
Most of the time
Sometimes
Almost never
Never
Comment
8
. Your age today is:
Your age today is:
0-49 yrs
50-59 yrs
60-69 yrs
70-79 yrs
80-89 yrs
90+
9
. Your gender
Your gender
Male
Female
10
. How long have you lived in Oakland?
How long have you lived in Oakland?
Less than 5 yrs
5-10 yrs
More than 10 years
I don’t live in Oakland
If you don't reside in Oakland, please tell us your city of residence
11
. Do you currently work in a paid or unpaid position?
Do you currently work in a paid or unpaid position?
Fulltime ~ 40 hrs/week
Part-time ~ 20+hrs/week
Less than 20 hrs/wk
No, I do not work or volunteer
Comment
12
. What is your typical mode of travel?
What is your typical mode of travel?
I drive
Someone drives me places
I use public transit (Bus/BART)
I use Paratransit
I bike
I walk
Other (please specify)
13
. What best describes your Living Arrangement?
What best describes your Living Arrangement?
I live alone
I live with my spouse/partner
I live with a family member
I live with friends
Other (please specify)
14
. How would you describe your health?
How would you describe your health?
Excellent
Good
Fair
Poor
My health conditions make it difficult for me to participate in activities
Comment
15
. Do you have medical insurance?
Do you have medical insurance?
Medicare
MediCal
Both MediCal and MediCare
Private coverage
I do not have medical insurance
16
. How would you describe your race/origin?
How would you describe your race/origin?
Caucasian
Black, African American
Hispanic/Latino
Chinese
Korean
Vietnamese
Filipino
Pacific Islander
Other (please specify)
Powered by
SurveyMonkey
Check out our
sample surveys
and create your own now!
Javascript is required for this site to function, please enable.