1. With whom do you live? (check all that apply) | 2. You are presently (check one): | ||||||
Alone Spouse or partner Child Other (specify): | Single/never married Married Divorced/separated Widowed Living with significant other | ||||||
3. Which of the following best describes your residence? (check all that apply) | 4. If living at a facility, please list the name and contact number of the person to contact if medical treatment is needed: | ||||||
Single-family house Condo/apartment Board and care/assisted living Nursing home Continuing care retirement community Other (specify): | Name of facility: | Name: Phone number:||||||
5. Do you consider yourself to be: | 6. How much school did you complete? | ||||||
Heterosexual or straight Gay or lesbian Bisexual Prefer not to answer | Less than 8th grade Some high school High school graduate Some college College graduate Graduate school | ||||||
7. How many children do you have? | 9. You are presently (check one): | ||||||
Retired/not working Working part-time Working full-time | |||||||
8. Are you in regular contact with your children? | |||||||
Yes | No | ||||||
10. Do you have a religious affiliation? | |||||||
Yes | No | ||||||
10a. If yes, please state: | |||||||
10b. If yes, do you actively practice? | Yes | No | |||||
11. List your principal occupation and any other significant past occupations: | |||||||
1. | 2. 3. 4. 5.|||||||
12. Please list name(s) and phone number(s) of those persons you would call if you were sick and needed help: | |||||||
Name: Phone number: Relationship: | Name: Phone number: Relationship: | ||||||
Name: Phone number: Relationship: | Name: Phone number: Relationship: | ||||||
12a. Do we have your permission to speak to the person(s) listed above on your behalf? | Yes | No | |||||
13. Compared with other people your age, how would you describe your health? | |||||||
Excellent | Good | Fair | Poor | ||||
14. Do you employ someone to provide health-related care or help you in your home? | |||||||
Yes | No | ||||||
14a. If yes, please list name(s) and contact information: | |||||||
14b. If yes, please indicate the number of hours per day and days per week your paid helper is available to you. | Hours per day: | Days per week:||||||
14c. Is this sufficient to meet your needs? | Yes | No | |||||
15. Do you get help from family members or friends in your home? | |||||||
Yes | No | ||||||
15a. If yes, please indicate the number of hours per day and days per week your family members(s) or friend(s) are available to you. | Hours per day: | Days per week:||||||
15b. Is this sufficient to meet your needs? | Yes | No | |||||
16. Do you provide care for a family member? | |||||||
Yes | No | ||||||
17. Do you currently use a home health care agency? | |||||||
Yes | No | ||||||
17a. If yes, please list name(s) and contact information: | |||||||
18. On any day in the past year, have you ever had: | |||||||
More than 3 drinks containing alcohol? | Yes | No | |||||
18a. Think about your typical week: | |||||||
| Days per week: | ||||||
| Drinks per day: | ||||||
19. Has anyone ever been concerned about your drinking? | |||||||
Yes | No | ||||||
20. Have you EVER used tobacco products including cigarettes? | |||||||
Yes (skip to 21) | No (skip to 22) | ||||||
21. Do you currently use tobacco products? | |||||||
Yes | No | ||||||
21a. If yes, what kind of tobacco products? | |||||||
| ¼ | ½ | 1 | 1½ | 2+ | ||
21b. If no, when did you quit? | Year: | ||||||
| Number of years: | ||||||
| ¼ | ½ | 1 | 1½ | 2+ | ||
22. Do you use marijuana? | |||||||
Yes | No | Prefer not to answer | |||||
22a. If yes, for what purpose? | Medical | Recreational |
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