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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!
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1
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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?
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2
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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 |
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3
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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 |
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4
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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 |
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5
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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.) |
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6
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Of all the PHYSICAL, SOCIAL, EDUCATIONAL and MEDICAL activities, please list the top four activities you are most interested in?
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7
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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 |
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8
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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 |
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9
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Do you volunteer for any professional, church, institutional, or not-for-profit entities?
| Yes |
| No |
| I would volunteer, if someone asked. |
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10
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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:
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11
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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+ |
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12
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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 |
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13
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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 |
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14
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What form of transportation do you use most?
| Walking |
| Bicycling |
| Bus |
| Taxi |
| Drive own car |
| Drive with others |
| Ride in a senior van |
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15
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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. |
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16
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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. |
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17
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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. |
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18
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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. |
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19
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Would you like more information about Aging Well?
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20
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Would you like to participate in a Focus Group to talk about interests and programs for the "55 and Better" Generation?
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21
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If you answered "YES" to either question, please complete:
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