Elder Needs Assessment survey instrument - National Resource ...

ELDER NEEDS ASSESSMENTThis survey is being conducted by Mt. Sanford Tribal Consortium which we hope will meet theneeds of the Elders in our communities. The purpose of the survey is to help us develop servicesthat will assist Elders to live comfortably in their community. This information is for planningpurposes only and information about individuals will kept confidential. Please help us byanswering the questions below.Person(s) completing survey: _____________________________________________________Senior # _____________Age: ____Ethnicity: Alaska Native ____ American Indian ____ Other_________What is your housing situation? Own home ____ Rent ____ Assisted Living ____ Other ____Type of Residence: Single Family Home ____ Apartment ____ Other _______Do you live: Alone ____ With Spouse ____ Spouse and Family ____ Family ____ (describe)Others (describe) _____________________________________________________________Number of people in your household ______Do you feel safe in your home? Yes ____ No ____ Explain____________________________________________________________________________________________________________________________________________________________Do you have problems with: Remembering Important Things ____Depression ____ Substance Abuse ____ Domestic Violence ____Rate your health: Good ____ Fair ____ Poor ____How many medications do you take? Prescription _______Non Prescription _____How many times a year do you go to the clinic? _____How many times a year do you go to ANMC? __________How many times have you stayed over night in a hospital in last 12 months? ____Have you ever stayed in Nursing home ____Long­term Care Unit ____Pioneer home ____Assisted Living Home ____If yes, what did you receive there that could not be provided for you at home?________________________________________________________________________