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* 1. What town do you live in?

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* 2. ZIP Code

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* 3. Here is a list of issues or activities that some people say are problems for older Americans. To what degree is each of these items a problem for you personally? (Please select one response to each item.)

  NO PROBLEM SOME PROBLEM SERIOUS PROBLEM
Availability of health care providers (doctors, hospitals)
Paying for prescription drugs
Affordable dental care
Affordable assistive devices (hearing aids, glasses, canes, etc.)
Getting information about services
Having someone check on me daily
Preparing nutritious meals
Personal Care (bathing, washing hair)
Homemaker services (shopping, housekeeping)
Getting information about disease prevention
Transportation
Transportation: Rural-Non Medical
Maintenance and repair of home
Accessibility modifications in my home (grab bars)
Maintenance of yard
Recreational or social opportunities
Counseling or mental health services
Bereavement/grief counseling/hospice services
Finding legal assistance
Getting information about health insurance (AHCCCS, Medicare, Medigap, etc.)
Cost of housing
Income (having enough money for basic needs)
Cost of energy/utilities
Employment opportunities
Age discrimination (loans, insurance, employment)
Elderly abuse, exploitation
Personal Safety (Crime)
Telemarketing or In-Home Sales
Loneliness
Loss of spouse/loved one
Volunteer opportunities
Raising grandchildren
Obtaining information on selecting nursing home or assisted living facility
Processing monthly bills and/or medical claims
Providing care and supervision for an elderly family member
Maintaining my personal independence

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* 4. Whom do you usually go to for advice about your health insurance or Medicare? (Select all that apply):

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* 5. What is your source of transportation? (Select all that apply)

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* 6. Select the group that contains your age

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* 7. Gender

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* 8. What is your racial/ethnic origin?

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* 9. Primary language spoken?

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