Area Plan 2012-2016 Needs Assessment Survey

INTRODUCTION

Are you 55 years or older? OR Are you an adult family member, neighbor, or friend who provide unpaid help to an elderly person or someone with Alzheimer’s or dementia?

WE NEED YOU!

By completing the following survey, you will help the County of Marin's Area Agency on Aging and the Commission on Aging understand the needs and concerns of older adults and family/informal caregivers. This will guide us in determining our goals, activities, and funding priorities for the next 4 years. While you may find some of the questions personal, your responses are kept confidential. We do not ask for your name or any other information that will identify you as the responder. Complete one survey per person.

Question Title

* 1. Please respond to this survey based on the perspective of the person checked below.

The information I’m providing in this survey is for (check only one)

A client

A family member/friend I'm taking care of

Myself

Question Title

* 2. Compared to other people the same age, you consider your health to be

Excellent

Good

Fair

Poor

Question Title

* 3. Have you had any of the following check-ups in the past 12 months? Check all that apply

Regular dental care

Regular eye care

Routine medical or physical examination

Question Title

* 4. Tell us about your nutritional health by answering the following questions

	Yes	No
Have you made changes to your lifelong eating habits due to health problems?	Have you made changes to your lifelong eating habits due to health problems? Yes	Have you made changes to your lifelong eating habits due to health problems? No
Do you eat fewer than 2 meals a day?	Do you eat fewer than 2 meals a day? Yes	Do you eat fewer than 2 meals a day? No
Do you eat less than 5 servings of fruits and vegetables a day?	Do you eat less than 5 servings of fruits and vegetables a day? Yes	Do you eat less than 5 servings of fruits and vegetables a day? No
Do you eat less than 2 servings of milk/ dairy/calcium fortified products a day?	Do you eat less than 2 servings of milk/ dairy/calcium fortified products a day? Yes	Do you eat less than 2 servings of milk/ dairy/calcium fortified products a day? No
Do you have tooth or mouth problems that make it hard for you to eat or chew?	Do you have tooth or mouth problems that make it hard for you to eat or chew? Yes	Do you have tooth or mouth problems that make it hard for you to eat or chew? No
Do you run out of money for food most months?	Do you run out of money for food most months? Yes	Do you run out of money for food most months? No
Do you eat alone most of the time?	Do you eat alone most of the time? Yes	Do you eat alone most of the time? No
Do you take 3 or more prescribed or over-the-counter drugs per day?	Do you take 3 or more prescribed or over-the-counter drugs per day? Yes	Do you take 3 or more prescribed or over-the-counter drugs per day? No
Without trying, have you gained or lost 10 or more pounds in the last 6 months?	Without trying, have you gained or lost 10 or more pounds in the last 6 months? Yes	Without trying, have you gained or lost 10 or more pounds in the last 6 months? No
Are you physically unable to shop, cook, or feed yourself?	Are you physically unable to shop, cook, or feed yourself? Yes	Are you physically unable to shop, cook, or feed yourself? No
Do you have 3 or more drinks of liquor, wine, or beer almost every day?	Do you have 3 or more drinks of liquor, wine, or beer almost every day? Yes	Do you have 3 or more drinks of liquor, wine, or beer almost every day? No

Question Title

* 1. Please respond to this survey based on the perspective of the person checked below. The information I’m providing in this survey is for (check only one)

Question Title

* 2. Compared to other people the same age, you consider your health to be

Question Title

* 3. Have you had any of the following check-ups in the past 12 months? Check all that apply

Question Title

* 4. Tell us about your nutritional health by answering the following questions

* 1. Please respond to this survey based on the perspective of the person checked below.

The information I’m providing in this survey is for (check only one)