The Questionnaire

Here is a sample of our questionnaire:

[The numbers in brackets are the scores. The scores are NOT shown to the respondents.]

Hi there! We are a group of Year 2 students from Social Work course, currently working on a research project to study whether the quality of life is dependent on the involvement of healthy lifestyle. Through this survey, we hope to get a better understanding of the current aging situation in Singapore, and if possible, to propose feasible suggestions to improve caregiving for elderly in general.

As our study targets elderly persons aged 50 and above, we seek your kind assistance in getting your parents/grandparents to fill up this questionnaire. It will take about 10-15 minutes. Thank you very much! J

Name:                                                                    Age:

1.      1. How many hours of sleep do you get per day on average? 

¨  0 – 5 hours (0)

¨  6 – 8 hours (1)

¨  More than 8 hours (2)

2.      2. Which of the following can you do without assistance?

¨  Getting dressed (1)

¨  Eating a meal (1)

¨  Going to the washroom (2)

¨  Household chores (2)

¨  Walking outdoors (1)

¨  Climbing the stairs (2)

3.      3. How often do you experience these?

	Never	Rarely	Sometimes	Often
Happy	(0)	(0)	(1)	(2)
Do things you enjoy	(0)	(0)	(1)	(2)
Lose control of emotions	(2)	(1)	(1)	(0)
Interact with your family	(0)	(0)	(1)	(2)
Meet your friends	(0)	(0)	(1)	(2)
Participate in the community	(0)	(0)	(1)	(2)
Visit places of worship (church, mosque, temple, etc.)	(0)	(0)	(1)	(2)
Participate in religious activities	(0)	(0)	(1)	(2)

4.      4. How much of this food do you eat?

	None	A little	A lot
Fruits & Vegetables	(0)	(1)	(2)
Noodles, Rice & Bread	(0)	(2)	(1)
Oily/Fried Food	(2)	(1)	(0)
Canned/ Instant Food	(2)	(1)	(0)
Soft Drinks	(2)	(1)	(0)
Snacks (Biscuits, crackers, etc.)	(2)	(1)	(0)
Sweets (Chocolates, cakes, etc.)	(2)	(1)	(0)

5.      5. How often do you participate in these activities?

	Never (0)	Rarely (0)	Sometimes (1)	Often (2)
Sports (Badminton, Basketball, Soccer, etc.)
Aerobic Exercise (Running, Jogging, Swimming, Cycling, etc.)
Anaerobic Exercise (Weight-lifting, Sprinting, Jumping Rope, etc.)
Light Exercise (Yoga, Pilates, Qi Gong, Tai Chi, etc.)
Workouts (Sit-ups, push-ups, squats, etc.)
Others Please specify: ___________________

6.      6. How often do you do these?

	Never (0)	Rarely (0)	Sometimes (1)	Often (2)
Puzzles (Sudoku, crossword, etc.)
Strategic board games (Monopoly, chess, mah-jong, etc.)

Reading books & newspapers