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Jefferson County
New York
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Aging Needs Assessment
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W10=
*
First Name
*
Last Name
*
Date of Birth (mm/dd/yyyy)
*
Phone
*
Address
*
City
*
Postal Code
*
Do you need help getting an appointment for COVID vaccine?
*
Do you need help getting an appointment for COVID vaccine?
Yes
No
Do you need help in providing for your meals?
Do you need help in providing for your meals?
Yes
No
Do You need help with transportation getting to appointments?
Do You need help with transportation getting to appointments?
Yes
No
Do you need help getting healthcare?
Do you need help getting healthcare?
Yes
No
Do you need help affording utilities?
Do you need help affording utilities?
Yes
No
Do you need help affording your medication?
Do you need help affording your medication?
Yes
No
Do you need help affording proper housing?
Do you need help affording proper housing?
Yes
No
Do you need help providing care for another person?
Do you need help providing care for another person?
Yes
No
Do you have financial problems?
Do you have financial problems?
Yes
No
Do you need help performing every day activities such as bathing or walking?
Do you need help performing every day activities such as bathing or walking?
Yes
No
Do you feel sad or lonely?
Do you feel sad or lonely?
Yes
No
Are you a victim of a crime?
Are you a victim of a crime?
Yes
No
Do you have a disability?
Do you have a disability?
Yes
No
Are you in good health?
Are you in good health?
Yes
No
How many people live in the house besides you?
How many people live in the house besides you?
0
1
2
3
4+
Have you used Jefferson County Office for the Aging services previously?
Have you used Jefferson County Office for the Aging services previously?
Yes
No
*
Would you like Jefferson County Office for the Aging to contact you and see what services we can provide to you?
*
Would you like Jefferson County Office for the Aging to contact you and see what services we can provide to you?
Yes
No
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