Exit this survey Anderson Valley Health Center Senior Services Assessment Question Title * 1. Are you: 55-64 65-75 76-85 85+ Question Title * 2. What is your ethnicity? Caucasian (non-Latino) Hispanic or Latino Black Asian Other (please specify) Question Title * 3. What is your gender? Male Female Question Title * 4. Do you live in: Boonville Philo Yorkville Comptche Navarro Other (please specify) Question Title * 5. What is your living situation? In my own house In my own apartment or condo In my own trailer, mobile home, modular etc. In a rented house In a rented apartment or condo In a rented trailer, mobile home, modular, etc. In a relative's house, apartment, etc. In a retirement community Question Title * 6. Do you live alone or with family or friends? (mark all that apply) Alone With spouse/partner With other family With friends Question Title * 7. What is your total estimated household income per month (net or after taxes)? Include all sources of income including social security, the income of your spouse/partner, and any extra income: Question Title * 8. What would you say is the GREATEST PROBLEM facing seniors in Anderson Valley today? Question Title * 9. What would you say is the GREATEST HEALTH PROBLEM facing seniors in Anderson Valley today? Question Title * 10. Do you use or receive any of the following subsidized social services? (check all that apply) Special buses or vans Public housing In-home care Medicare Medi-Cal Social Security checks Food stamps/Cal-Fresh Help paying rent/bills NONE Other (please specify) Question Title * 11. What are the top 3 SOCIAL services that you need that you are not getting now? 1. 2. 3. Question Title * 12. What types of activities would you like to be doing that you are not already doing? (check all that apply) Opportunities to socialize Gardening Classes/education Volunteering Exercise: e.g. Walking/tai chi/yoga Computer Classes Other (e.g. Music, cooking, arts and crafts, etc.) Question Title * 13. Please select your top 5 priorities from the list below and rank them in order of priority with "1" being your top priority. (You may drag the options in order of priority). 1 2 3 4 5 6 7 8 9 10 11 12 Chronic illness support group(s) 1 2 3 4 5 6 7 8 9 10 11 12 Exercise options 1 2 3 4 5 6 7 8 9 10 11 12 Free/low cost dental services 1 2 3 4 5 6 7 8 9 10 11 12 Free/low cost foot care 1 2 3 4 5 6 7 8 9 10 11 12 Free/low-cost in-home visitation program 1 2 3 4 5 6 7 8 9 10 11 12 Health education presentations 1 2 3 4 5 6 7 8 9 10 11 12 Help understanding insurance options 1 2 3 4 5 6 7 8 9 10 11 12 Hospice care 1 2 3 4 5 6 7 8 9 10 11 12 Mental health Programs 1 2 3 4 5 6 7 8 9 10 11 12 Physical or occupational therapy 1 2 3 4 5 6 7 8 9 10 11 12 Transportation services 1 2 3 4 5 6 7 8 9 10 11 12 In-home skilled nursing care Question Title * 14. Please select your top 5 priorities from the list below of services for seniors provided in the home and rank them in order with "1" being your top priority: (You may drag the options in order of priority) 1 2 3 4 5 6 7 8 9 10 11 Assistance with goal setting 1 2 3 4 5 6 7 8 9 10 11 Attend medical appointments with me 1 2 3 4 5 6 7 8 9 10 11 Coordinate supportive services 1 2 3 4 5 6 7 8 9 10 11 Health Education 1 2 3 4 5 6 7 8 9 10 11 Help schedule medical appointments 1 2 3 4 5 6 7 8 9 10 11 Home Safety assessments 1 2 3 4 5 6 7 8 9 10 11 In-home companion/social visits 1 2 3 4 5 6 7 8 9 10 11 Medication assistance/delivery 1 2 3 4 5 6 7 8 9 10 11 Mental Health support 1 2 3 4 5 6 7 8 9 10 11 Provide respite care 1 2 3 4 5 6 7 8 9 10 11 Chronic illness support Question Title * 15. Please select your top 5 priorities from the list below of health and wellness topics you would like to learn about and rank them in order of priority with "1" being your top priority: (You may drag the options in order of priority) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Accessing senior health services 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Advance Directives/end of life care options 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Coping with grief and loss 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 CPR class 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Depression 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Diabetes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Driver Safety 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Elder abuse prevention 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fall prevention/improving balance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fraud prevention 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Healthy nutrition and recipies 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Heart health 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Home Safety 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Managing Chronic Illness 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Medication Safety Question Title * 16. Do you have the following (select all that apply): Mobile phone with internet access Computer with internet access at home No access to internet Question Title * 17. On a scale of 1-10 please rate your ability to use your mobile phone or computer to access health information and/or support your health (i.e. use an online platform or portal)? ( "1" being not at all and "10" being extremely comfortable) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 18. If you needed health services, which of the following may prevent you from getting those services? (check all that apply) Cost Inconvenient hours Eligibility restrictions Lack of transportation Long waits Services not available Inadequate insurance coverage Other Question Title * 19. Are you caring for someone in your home whom is unable to take care of themselves? Yes No Question Title * 20. If yes on #19...What is that person's relationship to you? My spouse/partner My parent or parent-in-law My grandchild Other (please specify) Question Title * 21. If you needed information about a health problem or available health services, who would you ask or where would you go to get that information? Question Title * 22. Please share other feedback on senior health and wellness here: If you have questions or concerns please call 895-3477 and ask for Faris