Questionnaire: 2nd Draft

Ok guys sorry for the delay but I now have the 2nd draft of the questionnaire with some revisions made to questions 8, 9 & 10 as suggested by you. Let me know what you think.

1. What is you age?

• Less than 65
• 65 - 70
• 71 - 75
• 76 - 80
• 81 - 85
• 86 - 90
• Over 90

2. Which of the following best describes your current living situation?

• Live alone
• Live with partner/spouse
• Live with family
• Live in sheltered accommodation
• Live in a care home

3. How do you consider your independence to be ?

• Very Important/vital
• Quite importnat
• No preference
• Not importnat
• Not at all important

4. On an avergare week, how often do you leave your home?

• Never
• Once a week
• 2-3 times a week
• 4-5 times a week
• Everyday
• More than once a day

5. Which of the following best describes your current family situation?

a)

• No family
• Partner/spouse

b)

• Parent(s)
• Sibling(s) (with or without children/grandchildren)
• 1-2 children (with or without grandchildren)
• 3-4 children (with or without grandchildren)
• 5 or more children (with or without grandchildren)

If you have not ticked anyting in in section b, please skip questions 6-8

6. Where does your family live? (Please tick all that apply)

• Within the same general area (walking distance)
• Within 2 - 10 miles
• Within 11 - 30 miles
• Within 31 - 60 miles
• In the UK
• Outside the UK

7. Which family members live closest to you?

• Parent(s)
• Sibling(s)
• Children

8. Which of the following best describes how often you see your family? (Please tick all that apply)

• Never
• Once a year
• Once every 6 months
• Once every 3 months
• Once a month
• Once a fortnight
• Once a week
• Several times a week
• Everyday

9. Do you worry that if you have an accident at home, you would be unable to get help?

• Yes
• No
• Not sure
• Depends on the situation

10. If there was a device that exisited to help you improve with your day to day life, would you like to have it in your home and use it?

• Yes
• No
• Maybe
• Depnds on the device

If you have ticked no, please ignore the rest of the questions

11. Which of the following functions of a device would help you retain your independence in your own home?

• Personal alarm/panic button
• Automatic lighting systems
• Automatic opening closing curtains
• Shopping home delivery service
• Reminders service for important events
• Fire sensors with automatic appliance shut off
• Fire sensors with sprinkler system
• Gas/carbon monoxide detectors
• Automatic cooker shut off when leaving home

12. Which of the following best describes your mobility in your home?

• I use a walking frame
• I use a walking stick
• I use a whellchair and I am not able to walk
• I walk unaided but not far
• I walk completely unaided

13. If you live in a home with stairs, do you use a stair lift?

• Yes
• No
• Not applicable

14. Are there any other additional suggestions/concerns/comments you would like to contribute?