Aging Well--Assessing the Interests of Adults "55 and Better"

AGING WELL is a program of the Northwest Colorado Visiting Nurse Association. If you are a "55 and Better" adult living in the Yampa Valley, we would greatly appreciate your help in determining your preferred activities, interests and needs. Thank you so much for your assistance!
1
Do you or any family members use any Senior Services provided by the Visiting Nurses Association, Council on Aging, Routt or Moffat County Social Services or other Departments?
If yes, which ones?
2
Which of the following PHYSICAL activities would you participate in, if offered? Check all that apply.
Aerobics
Bicycling
Jumping rope
Tennis
Downhill or Cross Country Skiing
Swimming
Golf
Mini golf
Sleigh and Hay rides
Horseback riding
Badminton
Ping pong
Shuffleboard
Croquet or Lawn Bowling
Bowling
Fishing
Walking groups
Bird watching
Hot tub/hot springs-gentle pool exercises
Gardening (raking, weeding) or Greenhouse gardening
Performing (ballroom, other dance)
Water Aerobics
Weight lifting
Billiards/Pool Table
Tai Chi, Yoga, or Pilates
Indoor track/space for walking
Meditation
Other, (Please List)
3
Which of the following SOCIAL activities would you participate in, if offered? Check all that apply.
Bingo
Bridge, Mah Jongg or other games (please list)
Crafts
Sewing, stitchery
Jigsaw Puzzles
Dances, Mixers or Ice Cream Socials
Musical Performances
Theatre
Bus Trips
Church/Spiritual activities
Other, (Please List)
4
Which of the following EDUCATIONAL activities would you participate in, if offered? Check all that apply.
Financial Planning
Insurance/Benefits Seminars
Travel Presentations or Travel Planning
Defensive Driving
Bible Study
Other, (Please List)
5
Which of the following MEDICAL activities would you participate in, if offered? Check all that apply.
Prescription Drug Seminars
General Health, Dental, Vision or Hearing Screenings
Holistic Health or Alternative Medicine Information
Advance Directives (Living Wills, Organ Donations, etc.)
Other, (Please List)
6
Of all the PHYSICAL, SOCIAL, EDUCATIONAL and MEDICAL activities, please list the top four activities you are most interested in?
1.:
2.:
3.:
4.:
7
What other Programs/Group Activities do you take part in?
Yampa Valley Medical Center Seminars
The Haven Activities
Parks and Recreation
LRC, Over the Hill Gang or Other Social Groups (please list below)
Botanical Gardens
Strings
Other
8
At what rate do you participate?
Once a week
Twice a week
More than twice a week
Once a month
Once a season
Once a year
9
Do you volunteer for any professional, church, institutional, or not-for-profit entities?
Yes
No
I would volunteer, if someone asked.
Which ones do you participate in?
10
Do you possess special skills, talents, wisdom or experiences that you would be willing to share with others? Please tell us a little about that:
11
Which is your chronological/physical age?
50-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
91-95
96-100
100+
12
Where do you live?
Unincorporated Routt County
Unincorporated Moffat County
Steamboat Springs
Craig
Hayden
Milner
Oak Creek
Dinosaur/Brown’s Park
Maybell
Phippsburg
Yampa
Clark
Hahn’s Peak/Columbine
Other, please specify
13
With whom do you live?
I live alone in my own home or apartment
I live with my wife/husband in our own home or apartment
I live with an adult family member
I live with another adult who is not related to me
Other, please specify
14
What form of transportation do you use most?
Walking
Bicycling
Bus
Taxi
Drive own car
Drive with others
Ride in a senior van
15
On your PHYSICAL HEALTH, select the one that shows how you feel now:
Tip top condition, feel like a million bucks.
Most days, I’m really energetic.
Average for my age.
Could use some inspiration.
Most days in pain or discomfort.
16
On your SOCIAL HEALTH, select the one that shows how you feel now:
Have over 15 friends I see regularly; I am a real social butterfly.
I get out weekly to interact with folks in my age group and other age groups.
I have a balance of private quiet times with seeing folks I enjoy.
Don’t get out as much as I would like; I am alone a lot.
Basically hang out in my room, am lonely and blue.
17
On your FINANCIAL HEALTH, select the one that shows how you feel now:
I have an incredibly successful life that allowed a comfortable retirement.
I have a budget but still get to see family and friends as much as I would like.
I have a budget that must be followed closely. I do occasionally indulge myself but not as much as I would like.
I am constantly worried about how to make ends meet.
I am in debt without enough revenue and/or assets to meet my basic needs of food and shelter.
18
On your MENTAL HEALTH, select the one that shows how you feel now:
I wake-up every morning cheerful and embracing life to the fullest.
Most days are fulfilling, happy and positive.
Generally have good days that outnumber the bad ones.
Could use some cheering up and attention.
Constantly wish things were better.
19
Would you like more information about Aging Well?
20
Would you like to participate in a Focus Group to talk about interests and programs for the "55 and Better" Generation?
21
If you answered "YES" to either question, please complete:
Name::
Address::
City/State/Zip::
Phone::
Email address::
Thanks for your input!