c


m
1. Are you suffering from any of the following health problems:-

1.m Osteoarthritis
2.m Hypertension
3.m Diabetes
4.m Poor Vision / cataract
5.m Cough
6.m Any other

2. Is there any impairment of memory?

Y/N

3. Do you think because of increasing age you are having less of the social

interaction?

Y/N

4. Has your aging led to the decreased income capacity?

Y/N

5. Do you think your increasing age is increasing the propensity for accidents?

Y/N
6. In case of sickness does your children or family members help you?

Y/N

If yes, in what way,

a. Take you to the doctor

b. Give you medicine regularly

c. Provide financial, emotional and social support

7. Do you think any of the following has role in your disarranged health profile-

a. desi ghee

b. junk food

c. alcohol

d. excessive salt sugar consumption

e. any other

8. Do you think your increasing age has led to increased use of medicines?

Y/N

9. Under which category we can group them-

a. Fit, no major health problem

b. No chronic problems, but assistance needed

c. Restricted activity with one or more chronic problems

d. but not bed-ridden

10. Kind of care, you are taking«

a. No care

b. Allopathic

c. Indigenous doctors

d. Paramedical care

e. Home remedies