Older Adult Assessment
Behavioral Health and Support Assessment Questions - Older Adults
OPEN-ENDED QUESTIONS
1. What are the top three issues facing seniors in Shrewsbury, and why? *
1 point
Your answer
2. If there were two areas you could positively impact as it relates to seniors in Shrewsbury, what would they be? *
1 point
Your answer
3. Are there services or recreational activities that you or your friends would like, but do not exist (social or support groups, exercise/nutrition classes, etc.)? *
1 point
Your answer
4. What are some problems that seniors face when trying to access existing social services in Shrewsbury (counseling, fuel assistance, etc.)? What makes it difficult to get the help that might be needed? *
1 point
Your answer
SURVEY QUESTIONS: The following is a list of needs that YOU may have. Please indicate whether each item is a major need, a minor need, or is not a need for you. *
10 points
Major Need
Minor Need
Not a Need
Affordable and safe housing
Access to Organized Social Activities
Home care services (social support/care coordination)
Accessing/Transportation to Programs and Resources
Transportation for shopping or recreation
Counseling (for depression, anxiety, other)
Meaningful Work or Volunteer Options
Locating programs/resources
Caregiver support
Transportation for medical needs
For the following questions, please fill in the answers that best describe you.
1. How often do you feel isolated or lonely? *
1 point
2. How often do you feel sad or depressed? *
1 point
3. How long do your feeling of sadness or depression last? *
1 point
4. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities? *
1 point
5. During the past 12 months, how many times did you do something to purposely hurt yourself without wanting to die, such as cutting or burning yourself on purpose? *
1 point
6. During the past 12 months, did you ever seriously consider attempting suicide? *
1 point
7. During the past 12 months, did you make a plan about how you would attempt suicide? *
1 point
8. During the past 12 months, how many times did you actually attempt suicide? *
1 point
9. How often do you feel anxious or consumed with worry? *
1 point
10. How often does your anxiety interfere with your daily activities? *
1 point
11. Do you experience panic attacks? *
1 point
12. During the past 30 days, on how many days did you have at least one drink of alcohol? *
1 point
13. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? *
1 point
14. During the past 30 days, how many times did you use prescription drugs at a dose higher than prescribed or not prescribed to you (Marijuana, Barbiturates, Benzodiazepines, Amphetamines, Sleep Medicines, Codeine, Morphine, OxyContin, Vicodin, etc.)? *
1 point
15. During the past 30 days, how many times did you use other drugs (Marijuana, Heroin, Cocaine, Methamphetamines, etc.)? *
1 point
16. Do you feel safe in your home environment? *
1 point
17. Have you ever been a victim of elder abuse or domestic violence? *
1 point
18. Have you ever been a victim of a financial scam? *
1 point
19. Do you have a trusted adult you feel comfortable talking to about things that bother you? *
1 point
DEMOGRAPHICS: Please fill in the answers that best describe you
1. Gender *
1 point
2. Age *
1 point
3. What is your sexual orientation? *
1 point
4. What are your living arrangements? *
1 point
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