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Older Adult Survey
A survey for older adults in the WNY area to better gather data to further support out mission of keeping older adults at home for as long as possible.
Requirements for this survey:
65 years or older
Live in Western New York
* Indicates required question
Email
*
Your email
How old are you?
*
65-69
70-79
80-89
90-99
100+
What town/city do you live in?
Your answer
Are you currently working?
Yes
No
Clear selection
What type of residence do you live in?
A house that I own
A house that I rent
An apartment in a house
An apartment in a building
A senior living apartment
An assisted living facility
A long term care facility, like a nursing home
Other:
Clear selection
Who do you live with?
I live alone
My husand/wife
My children
My grandchildren
A friend
A significant other
A family member (sister, cousin)
Other:
Are you happy with your current living situation?
Yes
No
Clear selection
Do you feel as if you have a low risk of falling at your current residence?
Yes
No
Clear selection
Do you receive supportive care from a caregiver, nurse, friend or family member for cooking, cleaning, grocery shopping, laundry, driving to doctor's appointments?
Yes
No
Other:
Clear selection
Do you receive supportive care from a caregiver, nurse, friend or family member for every day tasks such as getting dressed, eating, bathing, walking?
Yes
No
Other:
Clear selection
If you have a second floor or a basement where you live, do you use that floor?
Yes
No
No because I am unable to use the stairs
Clear selection
Are you able to bathe in your bath tub or shower?
Yes
Yes with assistance
No because I cannot get in/out of them safely
No for any other reason
Clear selection
Have you fallen within the past 3 months?
No and I plan on keeping it that way!
Yes, inside my home
Yes, outside in the community
Other:
Clear selection
If you currently live in your own home, do you wish to move into senior apartments or an assisted living facility?
Yes that was always the plan.
No I wish to stay in my own home.
Clear selection
If you are currently in an assisted living facility, do you feel safe at your facility?
Yes
No
Clear selection
Do you wish to move into a nursing home for long term care once it is needed?
Yes
No
Clear selection
Did you know that insurance will only cover one piece of equipment after a discharge from rehab or a hospital?
Yes, unfortunately
No I did not!
Clear selection
Submit
Clear form
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