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Anderson Valley Health Center Senior Services Assessment (Correct one)

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* 1. What language are you most comfortable in ?

English

Spanish

Other (please specify)

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* 2. What is your gender?

Male

Female

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* 3. What is your living situation?

Rent

Own

I live with my family/friends

I don't have housing

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* 4. Do you live alone or with family or friends? Mark all that apply.

Alone

With spouse/partner

With other family

With friends

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* 5. Are you worried about losing your housing?

Yes

Choose not to answer this question

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* 6. Are you caring for someone in your home who is unable to take care of themselves?

Yes

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* 7. Do you worry about being able to cover any of the following expenses? Mark all that apply.

Food

Utilities

Rent/housing payments

Transportation

Medical/Behavioral Health/Dental services

None of the above

Other (please specify)

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* 8. Do you use or receive any of the following subsidized social services? Mark all that apply.

Special buses or vans

Public housing

In-home care

Medicare

Medi-Cal

Social Security checks

Food stamps/CalFresh

Help paying rent/bills

None of the above

Other (please specify)

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* 9. Do you have the following? Mark all that apply.

Mobile phone with internet access

Computer with internet access at home

No access to internet

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* 10. How would you rate your ability to use your mobile phone or computer to access health information and/or support your health (i.e. using an online platform or portal)?

Not comfortable

Comfortable

Extremely comfortable

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* 11. If you need senior services, which of the following may prevent you from getting those services? Mark all that apply.

Cost

Inconvenient hours

Eligibility restrictions

Lack of transportation

Long waits

Services not available

Inadequate insurance coverage

Negative experiences with health care staff

Lack of translation services

I need someone to go with me

None of the above

Other

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* 12. Emotional Well-Being: Which of the following pertain to you? Mark all that apply.

Insomnia/Sleep problems

Loneliness

Depression

Worry about family members

Unspecified anxiety

Concern about mental/physical decline

Difficulty with accepting the aging process

Stress

Feeling physically/emotionally unsafe or both

None of the above

Other (please specify)

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* 13. Please check any of the following you are interested in:

Social groups

Support groups

Exercise groups

Games/Activities

None of the above

If you chose Games/Activites, what kind?

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* 14. Have you ever been prescribed or referred to Physical Therapy?

Yes

If yes, where did you go?

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* 15. ONLY IF YES ON #14: Were you able to access and complete the full number of visits prescribed for Physical Therapy?

Yes

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* 16. ONLY IF YES ON #14: What were the obstacles in completing Physical Therapy for you?

Long wait time

Distance

Lack of transportation

Inadequate health insurance coverage

Appointments were only available during regular working hours

Lack of motivation

Feeling that the experience was not effective

I didn't like the physical therapist

Other comments about physical therapy:

Anderson Valley Health Center Senior Services Assessment (Correct one)

Question Title

* 1. What language are you most comfortable in ?

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* 2. What is your gender?

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* 3. What is your living situation?

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* 4. Do you live alone or with family or friends? Mark all that apply.

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* 5. Are you worried about losing your housing?

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* 6. Are you caring for someone in your home who is unable to take care of themselves?

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* 7. Do you worry about being able to cover any of the following expenses? Mark all that apply.

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* 8. Do you use or receive any of the following subsidized social services? Mark all that apply.

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* 9. Do you have the following? Mark all that apply.

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* 10. How would you rate your ability to use your mobile phone or computer to access health information and/or support your health (i.e. using an online platform or portal)?

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* 11. If you need senior services, which of the following may prevent you from getting those services? Mark all that apply.

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* 12. Emotional Well-Being: Which of the following pertain to you? Mark all that apply.

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* 13. Please check any of the following you are interested in:

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* 14. Have you ever been prescribed or referred to Physical Therapy?

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* 15. ONLY IF YES ON #14: Were you able to access and complete the full number of visits prescribed for Physical Therapy?

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* 16. ONLY IF YES ON #14: What were the obstacles in completing Physical Therapy for you?

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* 17. What would you say is THE GREATEST PROBLEM seniors are facing in the Anderson Valley today?

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* 18. What would you say is THE GREATEST HEALTH PROBLEM seniors are facing in the Anderson Valley today?