Participant Intake Questions for Registration Form

If you would prefer, we can call you to complete this survey with you over the phone. Please contact lgorman@parkwoodmh.com.

Please complete the bottom question to add your name and contact information.

Question Title

* 1. Do you identify or belong to any of the following groups? Check all that apply.

Male

Female

Identify as other than male or female

Francophone seniors

LGBT2SQ seniors

Indigenous seniors (First Nations, Métis, Inuit)

Visible minorities

Live in a rural area

New immigrant

Seniors with developmental disabilities

Live alone

Widower/s, Divorcees, Single seniors

Care givers

Seniors with physical disabilities

Asian

Latin

Central or South American

African

Caribbean

Oceanian

European

Other- Please specify

Question Title

* 2. What is your age group?

Aged 85 and over

Between 75 and 84

Between 65 and 74

Between 55 and 64

Under 55

Question Title

* 3. How would you rate your current level of loneliness

Not at all lonely

Somewhat lonely

Very lonely

Not at all lonely

Somewhat lonely

Very lonely

Question Title

* 4. Please tell us how many recreation or social programs you usually attend each week: (exercise, trivia, cooking, education, etc.)

	In person (if applicable)	Online (Virtual, e.g.: Zoom, facetime, YouTube)	Telephone
0-1 time	0-1 time In person (if applicable)	0-1 time Online (Virtual, e.g.: Zoom, facetime, YouTube)	0-1 time Telephone
2-3 times	2-3 times In person (if applicable)	2-3 times Online (Virtual, e.g.: Zoom, facetime, YouTube)	2-3 times Telephone
4 or more times	4 or more times In person (if applicable)	4 or more times Online (Virtual, e.g.: Zoom, facetime, YouTube)	4 or more times Telephone

Question Title

* 5. How many times per week do you usually talk to your family?

	In person (If applicable)	Online (Virtual, e.g.: Zoom, Facetime)	Telephone	Letters
0-1 time	0-1 time In person (If applicable)	0-1 time Online (Virtual, e.g.: Zoom, Facetime)	0-1 time Telephone	0-1 time Letters
2-3 times	2-3 times In person (If applicable)	2-3 times Online (Virtual, e.g.: Zoom, Facetime)	2-3 times Telephone	2-3 times Letters
4 or more times	4 or more times In person (If applicable)	4 or more times Online (Virtual, e.g.: Zoom, Facetime)	4 or more times Telephone	4 or more times Letters

Question Title

* 6. How many times per week do you usually talk to your friends?

	In person (If applicable)	Online (Virtual, e.g.: Zoom, Facetime)	Telephone	Letters
0-1 time	0-1 time In person (If applicable)	0-1 time Online (Virtual, e.g.: Zoom, Facetime)	0-1 time Telephone	0-1 time Letters
2-3 times	2-3 times In person (If applicable)	2-3 times Online (Virtual, e.g.: Zoom, Facetime)	2-3 times Telephone	2-3 times Letters
4 or more times	4 or more times In person (If applicable)	4 or more times Online (Virtual, e.g.: Zoom, Facetime)	4 or more times Telephone	4 or more times Letters

Question Title

* 7. Are you able to communicate with friends and family online?

Yes

Question Title

* 8. Would you like training on how to use the internet and social media?

Yes

Question Title

* 9. Do you have regular access to equipment to access the internet? (iPhone, tablet, computer)

Yes

Question Title

* 10. Would you like to increase your access to equipment that would allow you to be more active online?

Yes

Question Title

* 11. Do you get your information about Fairview/Parkwood online?

Yes

Question Title

* 12. Do your friends and family get information about Fairview/ Parkwood online?

Yes

Question Title

* 13. Which of the following activities would you be interested in attending online or by telephone? Check all that apply.

Bingo

Hymn sing

Book club

High German Club

Devotions with Various Community Leaders

Mid-Week Prayer Time

Reading Buddies with Schoolchildren

Virtual Friendly Visit

Cooking Tutorial

Craft Club

Group Discussion on Various Topics

Group Chat with Parkwood Staff

Volunteer will call you to Check In

Bible Study

Exercise Class/ Chair Exercise

Church Service with Pastor Alan

Concerts

Trivia and Games

Emotional Wellbeing Programs (Meditation, Spiritual)

Snoezelen - sensory activities

Virtual games (e.g., chess, scrabble, videogames)

Virtual movie watching

Novel/biography reading and analysis

Attending University lectures (Virtual).

Travelogues, virtual hikes and sightseeing tours

Other (please specify)

Question Title

* 14. Which of the following times work for you to participate in a virtual or online activity? Check all that apply.

No Preference

Morning

Afternoon

Early Evening

Question Title

* 15. Which of the following video or phone systems do you have access to?

None

Telephone Call-in

Face Time

Skype

Zoom

Other (please specify)

Question Title

* 16. Which of the following best describes your relationship to Parkwood?

Resident

Family Member

Volunteer

Wellness Centre Member

Family Council Member

Other (please specify)

Question Title

* 17. In order for us to contact you and set activities up in the future via phone, mail, or email can you please provide:

Name

Address

City/Town

State/Province

Email Address

Phone Number