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* 1. Full name:

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* 2. Which age group are you in ?

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* 3. Please give your postcode or area you live in?

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* 4. Select issues or concern you have or come across in your community.

  1 - slight concern 2 - quite worried 3 - worried 4 - very worried 5 - major worry/concern n/a
General Health
Having Independence
Living with a long term illness or disability
Feeling isolated or lonely
Money worries
Keeping (a home) warm
Transport or getting to places
Caring for a home or garden
Caring for pets
Caring for a partners or family member
How to maintain contact with family and friends
Keeping physically active
Eating a healthy diet or access to fresh food
A suitable place to live (house or location)

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* 5. What are the barriers that stop your from taking part in activities in the community?

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* 6. Where do you go for your provisions or leisure.

  Daily 2-3 times a week Weekly 2-3 times a month Monthly Occassionally
Cannich
Beauly
Drumnadrochit
Inverness
Dingwall
Other
Other

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* 7. Travel and online services.

  Yes No
Do You drive or have access to a car?
Do you rely on public transport?
Do you live alone?
Do you ever use online/internet services?

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* 8. How far are you prepared to travel for activities or services?

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* 9. If you could name three things that would make a difference to your life what would they be?

Thank you for taking part in this survey, this information will be used to assist in developing support and services for elderly and vulnerable people living in our communities.

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