Health Care Well-Being 


First of all, how would you evaluate the hospitals in your area in their ability to treat health problems related to age? 
 
 
  Excellent   
 
  Good   
 
  Fair   
 
  Poor   
 
  Not sure   
 
 
  
  
    How would you evaluate your overall health. Would you say you are:
 
 
 
  In good physical health. 
(No significant illnesses or 
disabilities. Only routine medical
care such as annual checkups required.)   
 
  Mildly physically impaired. (You have
only minor illnesses and/or 
disabilities which might benefit 
from medical treatment or 
corrective measures.)
  
 
  Moderately physically impaired. (You 
have one or more diseases or 
disabilities which are either 
painful or which require 
substantial medical treatment.) 
  
 
  Severely physically impaired. (You have 
one or more illnesses or 
disabilities which are either 
severely painful or life 
threatening, or which require 
extensive medical treatment.) 
  
 
  Totally physically impaired. (Confined 
to bed and requiring full-time 
medical assistance or nursing care 
to maintain vital bodily functions.)   
 
 
  
  
    What about the amount of social support you receive from your family, friends, and the like. When you have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs? 
 
 
  High degree of social support. (Much support is either given or is availablel, if needed, from family and friends.)   
 
  Above average degree of social support. (Given or potentially available from family and friends.)   
 
  Average degree of social support from family and friends is given or potentially available.   
 
  Below average degree of social support. (While some support is available from friends, there is no family member to help)   
 
  No support or potential support is available from either family or friends.   
 
 
  
  
    How often does a close friend or relative visit you in your home? 
 
 
  Daily   
 
  Several times a week   
 
  Weekly   
 
  Several times a month   
 
  Monthly or less often   
 
 
  
  
    Which of the following best describes your capacities to perform everyday activities: 
 
 
  You can perform all physical activities of daily living without assistance. (Excellent capacity)   
 
  You can perform all physical activities without assistance but may need some help with the heavy work such as laundry and housekeeping. (Good capacity)   
 
  You regularly require help with certain physical activities and/or heavy work but can get through any single day without help. (Moderate capacity)   
 
  You need help each day but not necessarily throughout the day or night. (Severely impaired capacity)   
 
  You need help throughout the day and/or night to carry out the activities of daily living. (Completely impaired capacity)   
 
 
  
  
    Can you get to places out of walking distances:

 
 
 
  Without help   
 
  With some help   
 
  Completely unable to travel unless special arrangements are made   
 
  Other    
 
 
  
  
    Can you do your own housework: 
 
 
  Without help   
 
  With some help   
 
  Completely unable to do any housework   
 
  Other    
 
 
  
  
    Can you go shopping for groceries:
 
 
 
  Without help   
 
  With some help   
 
  Completely unable to do any shopping   
 
  Other    
 
 
  
  
    Can you prepare your own meals?

 
 
 
  Without help   
 
  With some help   
 
  Completely unable to prepare any meals   
 
  Other    
 
 
  
  
    Can you do your own laundry?
 
 
 
  Without help   
 
  With some help   
 
  Completely unable to do any laundry at all   
 
  Other    
 
 
  
  
    
 
 
  
  
    Do you take care of your own appearance, things like comging your hair (for men shaving) etc? 
 
 
  Without help   
 
  With some help   
 
  Someone does all these types of things for you   
 
  Other    
 
 
  
  
    Do you dress and undress yourself? 
 
 
  Without help (pick out clothes, dress/undress self)   
 
  With some help   
 
  Does someone dress and undress you   
 
 
  
  
    During the past 24 hours, how many different kinds of medication have you taken? 
 
     

 
 
  
  
    If you have taken medication in the last 24 hours, how many of them have been prescribed by your physician?  
 
     

 
 
  
  
    If you have taken medication in the last 24 hours, do you take your medicine: 
 
 
  Without help (in the right doses at the right time)   
 
  With some help (take medicine if someone prepares it for you and/or reminds you to take it)   
 
  Completely unable to take your own medicines   
 
  Other    
 
 
 
 

  
    Number of members residing in your household: 
 
     

 
 
  
  
    What are your current living arrangements, in terms of your relation to the people you are living with?  
 
 
  Live with spouse only   
 
  Live with spouse and children   
 
  Live alone   
 
  Other