Health Care Survey for Elderly People

Knowledge, attitude and perception of senior citizens about their health risk and intention to use Smart Health Card

Name * :
Age * :
Gender * :
Aadhaar Number:
Contact Number:
Address:
1. Marital status
2. Education:
3. What do you do for living now?
4. Are you suffering from any condition where medical attention is required?
5. Do you have any problem in vision?
6. Do you have any problem in hearing?
7. Do you have any problem in chewing?
8. Do you feel any difficulty in daily life activities?
9. Do you have control on your urination?
10. Do you feel that you do not completely evacuate (not empty your rectum) when you have a bowel movement?
11. During a typical week, if weather permits, do you go outside the house?
12. In last 3 months have you experienced any weight loss? If YES
13. Do you take more than 5 medicines per day?
14. Have you got admitted in hospital in last 6 months?
15. Do you have any history of fall / slip during last 6 months?
16. Have you received any vaccine against pneumonia?
17. Do you receive regular vaccine (once a year) against flu (influenza)?
18. Are you feeling upset /depressed since last 2 weeks?
19. Do you enjoy the things the way you did 2 weeks before?
20. Do your family members think your memory has been affected? (For caregiver)
21. Do you have trouble falling asleep or staying asleep?
22. How do you rate your health?
23. Do you feel secure in your house or outside?
24. Do you have somebody with whom you can share your feelings?
25. Do you have somebody to help you during your times of crisis?
1. Do you have any problem in keeping all the previous record with you?
2. Do you have any problem to carry previous medical records with you during your visit to a doctor?
3. Would you be interested to use a smart card(like a debit card) to save your all medical data?
4. Would you be interested to use a smart card to produce your previous health records to your doctor?
5. Would you be interested to use smart card if it helps you to get discount in pharmacy?
6. Would you be interested to use smart card if it helps you to get discount in medical apparatus?
7. Would you be interested to use smart card if it helps you to get discount in medical bill in reputed hospital?
8. Would you be interested to use smart card if it helps you to get discount in surgical items?
9. Would you be interested to use smart card if it helps you to get discount in assisted devices?
10. Would you be interested to use smart card if it helps you to get discount in laboratory tests?
11. Would you be interested to use smart card if it helps you to get free accidental insurance of one lakh?
12. Would you be interested to use smart card if it helps you to get discount in emergency ambulance services?
13. Would you be interested to use smart card if it helps you to get free online medical consultation once in three months?
14. Would you be interested to use smart card if it helps you to get free and individualized healthy life style advice as per your need?
15. Would you be interested to use smart card if it helps you to get free and individualized preventive and curative strategies?
16. Is there anybody who can help you to get registered online for the smart card?
17. Is there anybody who can help you to upload your medical data for the smart card?
18. Do you feel the use of Smart Health Card a low budget health care solution?
19. Would you be willing to pay nominal annual subscription for this smart card, which will benefit you between 5 lakhs and 20 lakhs per annum as per your usage?
Thank you for participating in our survey