Caregiver survey: I need to ask you a series of questions so we can better help you. It will take about 10 minutes. No worries if you feel uncomfortable answering any of them or can’t answer them.
- Name:
- Phone number:
- Email address, if you use it:
- Text, if you use it:
- Name and relationship of person you care for:
- Are you x’s health care proxy?
- If so, do you have the signed document?
- If not, do you know who does?
- Does she live alone? If so, is there anyone who comes in to the house to help her out?
- If not, who lives with her?
- Are you in contact with any of these people?
- How often do you speak with person?
- Do you have a list of the names and contact information of xx’s doctors?
- Have you reviewed the ten key pieces of information you need from your mom? Please let me know if you need me to talk to your x about any of them.
- Would you like us to send you a weekly email explaining what we discussed with your x?____________________________________________
Older adult survey: Hello, xx asked me to call you. My name is y. X let me know that you are interested in participating in our pilot telebuddy program. We would like to call you once a week for about 20 minutes, learn about your health care questions and concerns, as well as to talk to you about ways to stay safe and healthy and to navigate the health care system. We are not doctors, and we cannot give you medical advice. But, we can give you health and wellness advice as well as advice about your health insurance. How does that sound to you? If OK, may I ask you a few questions so that we can better help you? If you would prefer not to answer a question, no worries.
Confirm Name:
Confirm Phone number:
Cell phone number:
Email address:
Do you use email?
- Yes
- No
Do you use text message?
- Yes
- No
Describe the community that you live in?
- Urban
- Suburban
- Rural
Do you live…
- Alone
- With significant other
- With family
- With a friend, roommate or housemate
Type of dwelling
- House
- Apartment
- Trailer
- Community living
Can you name the 10 people you speak to on a regular basis?
Are any of your neighbors friends of yours?
- Yes
- No
Are there people you can rely on in your community (friends, church members, etc)?
- Yes
- No
Do you do your own…
- Cooking
- Laundry
- Cleaning
- Shopping
- Bathing and dressing
Do you engage in any of these activities?
- Church
- Volunteer
- Exercise
- Other (Describe___________)
What kind(s) of insurance do you have?
- Medicare
- Medicare Advantage
- Medicaid
- Long-term care
Do you collect Social Security?
- Yes
- No
Do you have a doctor you trust and see on a regular basis?
- Yes
- No
Do you have a health care proxy?
- Yes
- No
If you answered yes to a health care proxy, is it yy (the caregiver who contacted us)?
Does your health care proxy have a copy? Does your doctor or another person have copy?
- Yes
- No
Are you on any medications?
- Yes
- No
How well do you sleep?
- Excellent
- Good
- Fair
- Poor
What is the best day and time to call you during the week?/Would it be OK if I called you each xx day at yy time?