Question

Sample questionnaire to older adults about their health

Answer 1

Q1. What is your name?

Q2. What is your date of birth?

D D M M Y Y Y Y

(Please ensure this is your
date of birth NOT today’s
date)

Q3. Under each heading, please tick the ONE box that best describes your health TODAY
Mobility
. I have no problems in walking about
. ​​​I have slight problems in walking about
. I have moderate problems in walking about
. I have severe problems in walking about
. I am unable to walk about
Q4. Self-Care
. I have no problems with washing or dressing myself
. I have slight problems washing or dressing myself
. I have moderate problems washing or dressing myself
. I have severe problems washing or dressing myself
. I am unable to wash or dress myself
Q5. Usual Activities (work, study, housework, family or leisure activities)
. I have no problems doing my usual activities
. I have slight problems doing my usual activities
. I have moderate problems doing my usual activities
. I have severe problems doing my usual activities
. I am unable to do my usual activities
Q6. Pain / Discomfort
. I have no pain or discomfort
. I have slight pain or discomfort
. I have moderate pain or discomfort
. I have severe pain or discomfort
. I have extreme pain or discomfort
Q7. Anxiety / Depression
. I am not anxious or depressed
. I am slightly anxious or depressed
. I am moderately anxious or depressed
. I am severely anxious or depressed
. I am extremely anxious or depressed

Q8. Do you agree with the following statements?
Yes No
a. I have an illness or condition that made me change the kind or amount of food I eat?

b. I eat fewer than two meals per day

c. I eat few fruits, vegetables, or milk
products

d. I have tooth or mouth problems that
make it hard for me to eat

e. I don’t always have enough money to buy the food I need

f. I eat alone most of the time

g. Without wanting to, I have lost or gained 10lb in the past six months

Q9. In general, would you say your health is:
1. Excellent
2. Very good
3. Good
4. Fair
5. Poor
6. Don’t know
7. Refused.
Q10. Compared with five years ago, how would you rate your health in general: better now, about the same or worse now?
1. Better now
2. About the same
3. Worse now
4. Don’t know
5. Refused.
Q11. Do you have any health problems that cause you difficulty in getting around and doing things for yourself?
1. Yes
2. No
3. Don’t know
4. Refused