COMMUNITY SURVEY FOR OLDER ADULTS (Age 60 and older)

Please complete the survey only once.  You may skip any question that you do not understand or are not comfortable answering. 

This survey will be open through February 24th, 2019.

Question Title

* Right now, how concerned are you about:

  Not Concerned Somewhat Concerned Very Concerned Not Applicable
Being able to live in your home as you get older
Being physically, emotionally or financially abused
Being the victim of a financial scam
Driving safely or not being able to drive
Falling or the fear of falling
Feeling lonely or being alone
Having enough money in retirement
Losing your memory or having dementia
Maintaining and repairing your home
Obtaining or understanding benefits (Social Security, Medicare, Medicaid)
Providing care to a spouse, partner or other loved one
Raising a grandchild or grandchildren
The amount of clutter or belongings in your home

Question Title

* How often do you:

  Never Sometimes Often Not Applicable
Attend community activities or events
Depend on someone else to drive you somewhere
Feel lonely or isolated
Visit with friends or family
Volunteer in the community

Question Title

* Do you:

  No Yes Not Applicable
Actively move about or exercise daily
Eat fruits and vegetables daily
Go to the dentist at least once a year
Go to the doctor at least once a year

Question Title

* Do you have difficulty paying for:

  No Yes Not Applicable
Assistive devices (hearing aids, eye glasses)
Dental care including cleanings, extractions
Enough food to eat
Fresh/healthy food to eat (fruits, vegetables)
Healthcare including doctor visits or hospitalizations
Medication
Rent, mortgage or property taxes
Transportation (gas, insurance, repairs, public transit)
Utilities (heating, cooling, water)

Question Title

* How difficult is it for you to:

  Not difficult Somewhat difficult Very difficult Someone does this for me Not Applicable
Clean the house
Do the laundry
Enter and/or exit your home
Get dressed
Handle paperwork/pay bills
Manage your medication
Prepare a meal
Shop for groceries
Shovel snow or complete yard work
Take a shower or bath

Question Title

* Please rate the following:

  Poor Fair Good Excellent
Your overall physical health
Your overall mental health
Your overall oral health
Your ability to live life with quality and dignity
Your community as a place to age well

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