Elder Survey

Question Title

* 1. What is your age?

50-55

56-60

61-65

66-70

71-75

76-80

81+

Question Title

* 2. What is your race?

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

More than one race

Other

Question Title

* 3. Are you Latinx/Hispanic

Yes

Question Title

* 4. What is your sexual orientation?

Asexual

Bisexual

Gay

Heterosexual or straight

Lesbian

Pansexual

Queer

None of the above, please specify

Question Title

* 5. What is your gender identity?

Cis Woman

Cis Man

Transgender Woman

Transgender Man

Genderqueer or non-binary

Agender

Not specified above, please specify

Question Title

* 6. How long have you been a patient at Callen-Lorde

less than a year

1-5 years

5-10 year

10-20 years

over 20 years

Question Title

* 7. In what language do you speak most often?

Arabic

Armenian

Chinese

English

French

Greek

Hindi

Italian

Japanese

Korean

Portuguese

Russian

Spanish

Vietnamese

Other (please specify)

Question Title

* 8. What is your insurance status?

Privately Insured

Medicare

Medicaid

Both Medicare and Medicaid

ADAP

Affordable Care Act Insurance

Other (please specify)

Question Title

* 9. How well do you feel that Callen-Lorde is equipped to provide you with health care as you age? (1 being not equipped 5 being very equipped)

Question Title

* 10. What services would you like to see at Callen-Lorde that would make you stay as you age?

Question Title

* 11. Are there health issues you feel like Callen-Lorde is not equipped to deal with? (for example cardiology)

Question Title

* 12. Why would you or would you not recommend Callen-Lorde to your peers?

Question Title

* 13. What social service/benefit navigation services do you feel you need (for example assistance with health insurance)?

Question Title

* 14. Do you need help navigating Medicare? If so, what would you like assistance with specifically (i.e. the donut hole, Part C)?

Question Title

* 15. What are your barriers to accessing medical care? (click all that apply)

Transportation

Health Insurance

Affording my care/medications

Mental Health

Technology

Mobility

Fear of COVID

Fear of discrimination (for gender identity/sexual orientation)

Other (please specify)

Elder Survey

Question Title

* 1. What is your age?

Question Title

* 2. What is your race?

Question Title

* 3. Are you Latinx/Hispanic

Question Title

* 4. What is your sexual orientation?

Question Title

* 5. What is your gender identity?

Question Title

* 6. How long have you been a patient at Callen-Lorde

Question Title

* 7. In what language do you speak most often?

Question Title

* 8. What is your insurance status?

Question Title

* 9. How well do you feel that Callen-Lorde is equipped to provide you with health care as you age? (1 being not equipped 5 being very equipped)

Question Title

* 10. What services would you like to see at Callen-Lorde that would make you stay as you age?

Question Title

* 11. Are there health issues you feel like Callen-Lorde is not equipped to deal with? (for example cardiology)

Question Title

* 12. Why would you or would you not recommend Callen-Lorde to your peers?

Question Title

* 13. What social service/benefit navigation services do you feel you need (for example assistance with health insurance)?

Question Title

* 14. Do you need help navigating Medicare? If so, what would you like assistance with specifically (i.e. the donut hole, Part C)?

Question Title

* 15. What are your barriers to accessing medical care? (click all that apply)

Question Title

* 16. Is there anything else you would like us to know?