NCE Homecare Senior Adult Health and Well-Being Survey on Behalf of Western CT Area Agency on Aging, Inc.
Western CT Area Agency on Aging, Inc.
Senior Adult Health and Well-Being Survey
Demographic Information
First Name
Last Name
Street Address
City
Zip Code
Email
Phone
Age
Gender
Male
Female
Other
Housing Information
Who resides in the home?
Alone
With spouse/partner
With family
Senior housing
Other
Do you have pets in your home? If yes, please specify the type and number of each pet (e.g. 2 dogs, 1 cat)
Yes
No
What type of housing do you currently live in?
House
Apartment
Mobile home
Shelter
Other
Do you rent or own your current residence?
Rent
Own
Other
How long have you lived at your current residence?
Less than 6 months
6 months to 1 year
1-2 years
2-5 years
More than 5 years
Have you had trouble paying for housing costs in the past year?
Yes
No
How stable do you feel your current housing situation is?
Very stable
Somewhat stable
Neutral
Somewhat unstable
Very unstable
How would you rate the condition of your current housing?
Excellent
Good
Fair
Poor
Have you experienced any of the following issues in your current housing? (Select all that apply)
Plumbing problems
Electrical issues
Structural problems
Pest infestations
Poor heating/cooling
Mold
Other
Do you have any additional comments or concerns about your housing situation that you would like to share?
Physical Health
How would you rate your overall physical health?
Excellent
Good
Fair
Poor
How often do you experience pain that affects your daily activities?
Never
Rarely
Sometimes
Often
Always
Do you have any chronic conditions? (e.g., diabetes, heart disease, arthritis)
Yes
No
How often do you engage in physical exercise (e.g., walking, stretching, fitness classes)?
Daily
Several times a week
Once a week
Rarely
Mental Health
How would you rate your overall mental health?
Excellent
Good
Fair
Poor
In the past month, how often have you felt sad or depressed?
Never
Rarely
Sometimes
Often
Always
How often do you feel anxious or stressed?
Never
Rarely
Sometimes
Often
Always
Do you have someone you can talk to about your feelings or concerns?
Yes
No
Social Well-Being
How often do you participate in social activities (e.g., visiting friends, group activities)?
Daily
Several times a week
Once a week
Rarely
Do you feel lonely or isolated?
Never
Rarely
Sometimes
Often
Always
How easy is it for you to perform daily activities (e.g., bathing, dressing, cooking)?
Very easy
Easy
Neutral
Difficult
Vey difficult
Do you need assistance with any daily activities?
Yes
No
Do you need help with household chores?
Yes
No
How would you rate your ability to manage medications and medical appointments?
Excellent
Good
Fair
Poor
Have friends or family members expressed concern about the condition of your home?
Yes
No
How would you describe the number of belongings in your home?
Minimal
Moderate
Excessive
Do you find it difficult to discard items, even those you no longer need or use?
Never
Rarely
Sometimes
Often
Always
Have you experienced any safety or health issues due to the amount of belongings in your home? (e.g., tripping hazards, fire hazards)
Yes
No
Safety and Well-Being
Do you feel safe in your home and living environment?
Never
Rarely
Sometimes
Often
Always
In the past year, have you experienced any of the following from someone close to you? (Select all that apply)
Yelling or verbal abuse
Threats or intimidation
Physical harm or violence
Being forced to do things against your will
Financial exploitation or theft
Neglect or lack of necessary care
Other
None of the above
Do you have someone you can trust and talk to about your well-being and safety?
Yes
No
Have you ever felt pressured or forced into making financial decisions you were not comfortable with?
Yes
No
Do you have any concerns about how you are being treated by family, caregivers, or others?
Yes
No
Would you like to receive information or assistance regarding safety and support resources?
Yes
No
Nutrition
How would you rate your overall diet?
Excellent
Good
Fair
Poor
How many meals do you eat each day?
1
2
3
More than 3
How often do you eat fruits and vegetables?
Daily
Several times a week
Once a week
Rarely
Never
How often do you consume dairy products or alternatives?
Daily
Several times a week
Once a week
Rarely
Never
How often do you eat whole grains (e.g., whole wheat bread, brown rice, oats)?
Daily
Several times a week
Once a week
Rarely
Never
How often do you eat lean proteins (e.g., poultry, fish, beans, nuts)?
Daily
Several times a week
Once a week
Rarely
Never
Do you have any dietary restrictions or special dietary needs? (e.g., low sodium, diabetic, gluten-free)
Yes
No
Do you have any difficulties preparing meals for yourself?
Never
Rarely
Sometimes
Often
Always
Do you have access to fresh and affordable groceries?
Never
Rarely
Sometimes
Often
Always
Are you satisfied with your current eating habits and diet?
Very satisfied
Satisfied
Neutral
Dissatisfied
Vey dissatisfied
Would you like to receive information or assistance regarding nutrition and healthy eating?
Yes
No
Transportation
What is your primary mode of transportation?
Personal vehicle
Public transportation (bus, train, etc.)
Rides from family/friends
Ride-sharing services (e.g., Uber, Lyft)
Community shuttle or senior transport services
Walking
Other
How often do you use your primary mode of transportation?
Daily
Several times a week
Once a week
Rarely
Never
Do you have any difficulties with transportation? (e.g., cost, availability, physical limitations)
Yes
No
How easy is it for you to access public transportation or other transportation services?
Very easy
Easy
Neutral
Difficult
Vey difficult
Do you feel that transportation options meet your needs for medical appointments, shopping, social activities, etc.?
Never
Rarely
Sometimes
Often
Always
Would you like more information or assistance regarding transportation options available to you?
Yes
No
General Well-Being
How would you rate your overall quality of life?
Excellent
Good
Fair
Poor
Do you feel you have a purpose in life?
Yes
No
Is there anything else you would like to share about your health and well-being?
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