1. In general, how would you say your health is?

2. Compared years ago, how would you rate your health now?

3. In the 12 months, have you consulted a doctor about your health?

4. Does your health limit you in doing activities such as walking, running or lifting?

5. Does your health cause you difficulty in getting around and doing things for yourself?

6. How often do you feel sad?

7. How often do you feel nervous?

8. How often do you feel lonely?

9. How often do you hopeless?

10. How often do you feel restless?

Directions: Using the rating scale below, check the box the corresponds to your answer.

4 – Excellent
3 – Very Good
2 – Good
1 – Poor

4 3 2 1
Safety of the housing
Food Quality
Healthy Environment
Cleanliness of Bathrooms
Cleanliness of Bedrooms
Staff is respectful
Staff is careful
Staff is orderly
Staff is patience
Staff is reliable