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* 2. Age range:

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* 3. Are you or your spouse a Veteran?

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* 4. How difficult is it for you to:

  No Help Needed Getting All the Help Needed Getting Some of the Help Needed Not Getting Any of the Needed Help N/A
Find information on available services
Find transportation to doctors/medical appointments
Address your personal needs (bathing, dressing, etc.)
Shop for groceries
Prepare your daily meals
Clean your home
Being able to afford heat or other utilities
Handle your own money and/or paying your bills
Maintain your home (shoveling, mowing, small repairs, etc.)
Afford medications
Manage medication (preparing/taking)
Understand and complete health insurance or Medicare forms
Provide care for another person as a caregiver
Spend time with friends and family
Obtain legal advice or assistance

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* 5. Gender:

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* 6. Marital Status:

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* 7. I live:

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* 8. Which best represents your race:

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* 9. Are you Hispanic or Latino?

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* 10. Annual income:

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* 11. I attend a Senior Center/Nutrition site:

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* 12. Which center do you attend?

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* 13. What is your preferred source of information? (check all that apply)

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* 14. Check which services you feel are the top 5 critical needs in the community:

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* 15. Please provide any additional comments, suggestions, or ideas:

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