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  1. Surveys
  2. 2010
  3. December
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Exit Survey »
 
 
Part 1 General Information

Please tell us a little about yourself by checking the response that best describes you.
 
 
1. Your county of residence is?
 
Bullitt
 
Henry
 
Jefferson
 
Oldham
 
Shelby
 
Spencer
 
Trimble
 
Other
 
 
 
What is your zip code?
   
 
 
2. What is your age?
 
Under 50
 
50-59
 
60-64
 
65-74
 
75-84
 
85 or older
 
 
3. Are you...
 
Male
 
Female
 
 
4. What is your race or ethnic background?
 
African-American/ Black
 
American Indian/ Native American
 
Latino/ Hispanic
 
White
 
Asian
 
Other
 
 
 
5. Where do you live right now?
 
My own house
 
Retirement Community
 
Condominium/ Patio Home
 
With my parent in his/ her home
 
My own apartment
 
Senior Housing Complex/ High Rise
 
Assisted Living Facility
 
With my child in his/ her home
 
Other
 
 
 
6. Please indicate your household level of income:
 
Less than $10,800
 
$10,831-$16,425
 
$16,426-$25,000
 
$25,001-$55,000
 
$55,001-$85,000
 
$85,001 +
 
 
7. How many people live in your household?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
More than 8
 
 
 
Part 2 Medical and Insurance Information
 
 
1. How would you rate your personal health?
 
Excellent
 
Very Good
 
Good
 
Fair
 
Poor
 
Very Poor
 
 
2. Do you have any of the following chronic health issues? (check any or all that apply)
 
Diabetes
 
High Blood Pressure
 
Arthritis
 
Prostate problems
 
Osteoporosis
 
Urinary Infections
 
Lung Problems (COPD, emphysema, etc)
 
Heart Problems
 
Other
 

 
 
3. Do you take medication?
 
Yes
 
No
 
 
How many prescriptions do you have?
   
 
 
4. How many of your medications can you afford?
 
None
 
A few
 
About half
 
Most
 
All
 
 
5. Do you have Medicare Part D prescription coverage?
 
Yes
 
No
 
 
6. Do you participate in community health screenings?
 
Yes
 
No
 
 
7. In terms of the amount of health insurance you have right now, what would you say?
 
I need a lot more
 
It's barely enough
 
It's about right
 
It's more than enough
 
 
8. Is your health insurance easy to use?
 
Yes, completely
 
Mostly
 
A little bit
 
No, not at all
 
 
9. How much of your medical costs are you able to pay?
 
None
 
A few of them
 
About half
 
Most
 
All of them
 
 
10. Do you have a disability or impairment?
 
Yes
 
No
 
 
What is your primary disability/ impairment?
   
 
11. If you are moving from the hospital back to your home, would any of the following services be helpful to you? (Check all that apply)
Yes Maybe No
Help in understanding the hospital discharge information
Help in understanding the type and use of medications
Help getting durable medical equipment
Help with personal care, homemaking, or meals
Help in understanding the medical bills
 
 
 
Part 3 Care Giving
 
 
1. Are you a caregiver for someone in your household or someone living nearby?
 
Yes
 
No
 
 
2. Who is the person you care for?
 
My spouse
 
Another relative
 
Someone who is not a relative

 
 
3. How old is the person you care for?
 
Under 18 years old
 
Between 18-59 years old
 
60 years old or older

 
4. As a caregiver, how much of a concern are the following areas for you?
Not at all Somewhat Very much
Having someone to talk to
Taking a break to meet your own needs
Dealing with agencies to get services
Getting information
 
 
 
Part 4 Long-Term Living and Planning
 
1. Below is a list of services that people sometimes use when they are unable to care for themselves or their loved ones. For each one, please check the boxes that best represent your current situation.
I currently use this service I plan to use this service I do not plan to use this service
A. Do you use, or plan to use, in-home services?
B. Do you use, or plan to use, adult day care?
C. Do you use, or plan to use, assisted living services?
D. Do you use, or plan to use, retirement community services?
E. Do you use, or plan to use, a subsidized apartment?
F. Do you use, or plan to use, a nursing facility?
 
2. Have you prepared any of the following legal documents for yourself?
Yes No
A. Advance Directives
B. Health Care Surrogate
C. Do Not Resuscitate (DNR)
D. Power of Attorney
E. Will
F. Banking Agent
G. Trust
 
2. Have you prepared any of the following legal documents for someone you care for?
Yes No
A. Advance Directives
B. Health Care Surrogate
C. Do Not Resuscitate (DNR)
D. Power of Attorney
E. Will
F. Banking Agent
G. Trust
 
 
 
Part 5 Your Quality of Life

Below is a list of concerns that could affect your quality of life. For each one, please check the box that best describes how much each one is a concern for you.
 
Safety
No Concern Minor Concern Major Concern
Feeling unsafe at home or in the neighborhood (crime)
Avoiding accidents, falling, or loss of balance
 
Income
No Concern Minor Concern Major Concern
Having enough money for food, shelter or clothing
Being able to pay for heat and other utilities
 
Home and Personal Care
No Concern Minor Concern Major Concern
Taking a bath (washing hair, shaving, etc.)
Cleaning your home
Getting in and out of bed or chair
Shopping and preparing meals
 
Transportation
No Concern Minor Concern Major Concern
Having a way to get to your doctor, pharmacy, etc.
Using public transit (bus, etc.)
Being able to drive your own car
 
Housing
No Concern Minor Concern Major Concern
Having/obtaining affordable housing
Finding help for home repairs
Having a safe access to home and rooms (wide doorways, handrails, etc.)
 
Social / Emotional Support
No Concern Minor Concern Major Concern
A place to go eat and socialize
Attending a religious gathering
Attending senior center
Visiting with family, friends, neighbors
Attending counseling services or support groups
Feeling lonely and sad
 
Emergency Plan
No Concern Minor Concern Major Concern
Knowing how to get a medical alert system
Developing an emergency plan (for natural disasters, etc.)
Having family or others you can call on to help in an emergency
 
 
Volunteer Work / Employment
 
 
Do you currently serve as a volunteer?
 
Yes
 
No
 
 
Are you currently employed
 
Part-Time
 
Full Time
 
Not at All
 
 
Have you retired and returned to employment?
 
Yes
 
No
 
 
Did you return to work for financial reasons?
 
Yes
 
No
 
 
Are you currently looking for work?
 
Yes
 
No
 
 
Do you feel that your monthly income is enough to cover your household expenses?
 
It's not enough
 
It's barely enough
 
It's about right
 
It's more than enough
 
 
 
Additional Comments:
   
 
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