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Anderson Valley Health Center Senior Services Assessment (Correct one)
1.
What language are you most comfortable in ?
English
Spanish
Other (please specify)
2.
What is your gender?
Male
Female
3.
What is your living situation?
Rent
Own
I live with my family/friends
I don't have housing
4.
Do you live alone or with family or friends? Mark all that apply.
Alone
With spouse/partner
With other family
With friends
5.
Are you worried about losing your housing?
Yes
No
Choose not to answer this question
6.
Are you caring for someone in your home who is unable to take care of themselves?
Yes
No
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)
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)
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
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
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
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)
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?
14.
Have you ever been prescribed or referred to Physical Therapy?
Yes
No
If yes, where did you go?
15.
ONLY IF YES ON #14: Were you able to access and complete the full number of visits prescribed for Physical Therapy?
Yes
No
16.
ONLY IF YES ON #14: What were the obstacles in completing Physical Therapy for you? Mark all that apply.
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:
17.
What would you say is THE GREATEST PROBLEM seniors are facing in the Anderson Valley today?
18.
What would you say is THE GREATEST HEALTH PROBLEM seniors are facing in the Anderson Valley today?
19.
What would you say are the
TOP 3
HEALTH SERVICES that you need that you are not getting right now?
Free/low cost in-home visitation program
Chronic illness support groups
Transportation services
Health education presentations
Free/low cost dental services
Free/low cost foot care
Dental care
Physical or occupational therapy
Help understanding insurance options
Hospice care
Exercise options
In-home skilled nursing care
Help scheduling medical appointments
Assistance with goal setting
Medication education
Home safety assessments
Mental health support
Provide respite care
Heart health
Diabetes
Advance Directives/End of life care
Driver safety
Fall prevention/Improving balance
Loneliness
Depression
CPR class
Healthy/Nutritious recipes
Elder abuse prevention
Fraud prevention
Accessing senior health services
Coping with grief and loss
20.
Please share other comments on senior health and wellness here:
21.
If you would like to be contacted, please put down your name and best number or method of contact: