Ageing Well Questionnaire Ageing Well Questionnaire Full Name * Date of Birth * NHS Number If Known PLEASE TICK EITHER ‘YES / NO / SOMETIMES’ & ADD ANY COMMENTS IF NEEDED IN THE BOX PROVIDED Mobility Can you do the following tasks without help from another person? (walking aids such as a cane or a wheelchair are allowed) Grocery shopping * Yes No Any further details? Walking outside of the house (around house or to neighbour) * Yes No Any further details? Getting dressed or undressed * Yes No Any further details? Visiting bathroom * Yes No Any further details? Vision Do you encounter problems in daily life because of impaired vision? * Yes No Any further details? Hearing Do you encounter problems in daily life because of impaired hearing? * Yes No Any further details? Nutrition Have you unintentionally lost a lot of weight in the past 6 months (6kg/13lb in 6 months or 3kg/6lb in 3 months)? * Yes No Any further details? Medication Do you use 4 or more different types of medication? * Yes No Any further details? Memory Does you have any complaints about your memory (or are you diagnosed with dementia)? * Yes No Sometimes Any further details? Social Does you ever experience emptiness? * Yes No Sometimes e.g. You feel so sad that you have no interest in your surroundings. Or if someone you love no longer loves you, how do you feel? Any further details? Do you ever miss the presence of other people around them? Or do you miss anyone you love? * Yes No Sometimes Any further details? Do you ever feel left alone? * Yes No Sometimes e.g. You wish there is someone to go with you for something important. Any further details? Have you been feeling down or depressed lately? * Yes No Sometimes Any further details? Have you felt nervous or anxious lately? * Yes No Sometimes Any further details? Physical Fitness How would you rate your own physical fitness? (0-10 ; 0 is very bad, 10 is very good) * Lifestyle questions Do you have caring responsibilities for others? * Yes No Any further details? Are you a smoker? * Yes No including cigarettes, rolled tobacco, pipe, vape. How many do you smoke a day? * Do you drink alcohol? * Yes No How many units per week? * 1 x 25ml shot of spirit = 1 unit 1 x standard 175ml glass of wine = 2 units 1 x pint lower strength beer/cider = 2 units Are you worried about fuel poverty? * Yes No e.g as a rough percentage of income, how much do you spend on heating? Are you in receipt of attendance allowance? * Yes No Have you had any falls in the last year? * Yes No How many? * Thank you for taking the time to complete this questionnaire If you are human, leave this field blank. Submit