SECTION 1: Quality of Life 

Quality of life includes your satisfaction with many different areas of your life.  These areas include your physical and mental health, your environment, relationships, and activities that you do for fun. This section has questions that can help us plan programs and resources to maintain or improve your quality of life. 

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* 1. How would you rate your overall quality of life? Please choose one response.

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* 2. How often are you able to participate in the following? Please choose one response in each row.

  As often as I want  Not quite as often  
as I want 
Not interested in this 
Community events, social clubs, support groups 
Sporting events 
Volunteer work 
Education programs  
Exercise, fitness, physical activities 
Family visits or activities 
Library visits 
Restaurants, eating out 
Park or nature visits 
Religion, worship services 
Senior center meals and activities 

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* 3. Are you able to do the following activities by yourself or with help? 
Please pick one in each row 

  I am currently able  I am not able, but I have the help I need  I am not able, and I do not have the help I need 
Cooking meals 
Cleaning the house 
Home maintenance 
Yard maintenance 
Shopping for necessities 
Transportation to medical appointments 
Finding information about services and supports 
Meet my social needs 
Care for another individual, without hurting my health
Protect myself from abuse and fraud 
Afford necessities such as groceries, gas, medications, utilities.
Take care of my chronic health needs like diabetes or heart conditions. 
Use a computer or personal device for health care or support 
Use a computer or personal device for fun or socialization 

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* 4. How often do you worry about the following topics

  Very frequently  Frequently  Not often  Never 
Crime in your area 
Friends or family committing suicide 
Friends or family becoming drug addicted 
Being prepared for a natural disaster 
Falling while walking 
Living in pain 
Being lonely 
Paying my bills 
Losing my housing 
Bowel or bladder accidents 
Problems with memory