Harris County Area Agency on Aging Needs Questionnaire

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* 1. Please identify yourself. You may check more than one box.

Person caring for someone over age 60.

Person caring for someone under age 60.

Person 60 years of age or older.

Person with a disability under age 60.

Other (please specify)

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* 2. What are the top (3) needs for you or the person you are caring for?

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* 3. Have you or the person in your care been in the hospital within the last six (6) months?

Yes

If yes, for what reason?

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* 4. Are you taking medication for an ongoing health condition?

Yes

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* 5. Have you had a fall within the last six (6) months?

Yes

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* 6. How many family members or friends do you see or talk to during the week?

One (1)

Two (2)

Three or Four (3 or 4)

Five to Eight (5 to 8)

Nine or more (9 or more)

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* 7. Who do you see or talk to almost every day?

My spouse or partner

A family member

Someone who helps me

Someone else

No one

Other (please specify)

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* 8. Do you have questions about Medicare?

Yes

If yes, what are they?

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* 9. Do you have questions about health insurance options available for people 60-64 years old?

Yes

If yes, what are they?

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* 10. How should the Area Agency on Aging outreach and educate the new generation of older adults (baby boomers) and their caregivers about its services and programs?

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* 11. What kinds of services and programs will make the community centers offering senior programs and meals more inviting for the new generation of older adults?

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* 12. How do you receive information about topics that interest you most? Check all that apply.

Television

Internet

Word of Mouth

Newspaper

Other (please specify)