Appendix A: Profile of Elderly

Profile of Elderly

Name :______________________________________________________________________

Sex :______________ Male ______________ Female

Age :_______________

Marital Status : ________ Single __________ Married ___________ Widow

Address : ___________________________________________________________________

Occupation : _______ Yes _______ No

Educational Attainment : ______ Elementary _____ High School _____ College

Living Condition : _________Alone _________With relatives ________With others

Pension : _______1-5 K _______6-10K _______ 11-15K _______>15K

Illness/es : _____Cardiovascular _____Musculoskeletal _____Pulmonary

_____Neurological _____Malnutrition ______Others

No. of Drugs Taken : _____1-3 _____4-6 ____7-10____>10

Ambulation :________ Yes _________ No _________ Partial

Hospitalization : ________ 1-2 times/year _________ 3-4 times/year _________ >5

times/year
 Appendix B: Survey Questionnaire for Home Caregiver
Survey Questionnaire for Home Caregiver
(for Pre-test)
Good day. This is a survey instrument for my research intended at developing a needs-
based health care model for indigent Filipino elderlies. Please fill-up this form. Your
responses will be valuable input in designing a model for quality health care for the
elderlies.

Name : ______________________________ Age: _______ Gender __________

Civil Status: ________________ Educational Attainment: ______________
Income ____________________ Length of caring for the elderly: ________
Type of housing _____________ (month/years)
Please fill-up attached profile of ward/loved one.

1 – Strongly Disagree 2 – Disagree 3 – Neutral 4. Agree 5. Strongly Agree

Statement 1 2 3 4 5 Explanation/Remarks
Experiences
I have trouble staying focused
1 on what I am doing as
caregiver.
I have difficulty making
2
decisions for my ward.
I feel I cannot leave my
3
relative/ward alone.
I feel overwhelmed with
4 managing multiple demands
(family, work, caregiving)
I feel resentful of my duty as
5
caregiver.
I feel helpless with my duty as
6
caregiver.
I feel useless with my
7
caregiving duties.
8 I feel lonely as a caregiver.
I fefl weary or tired doing my
9
caregiving duties.
I feel numb or drained of any
10
feeling while giving care.
I feel anxious while caring for
11
my ward.
I had a crying spells while
12
giving care.
I have been physically
13 exhausted during the time I
give care.
 I have been edgy or irritable as
14
a caregiver.
I have felt ill (headaches,
stomach problems, back pain,
15
or common cold) while caring
for my ward.
I lose or had poor sleep while
16
giving care to my ward.
I have either overeaten or had
17 a poor appetite during my
caregiving.
I have been upset that my
18 relative/ward has changed so
much from his/her former self.
Practices
I hold regular discussions with
19 my ward about his/her
preferences as he/she age.
I try to learn as much as I can
20 about my ward/loved one's
condition.
I discuss with the doctor about
21 the diagnosis of my
ward/loved one.
I research on my own about
22 the condition of my
ward/loved one.
I have contact with local health
23 providers such as midwives
and doctor.
I meet with the family of my
24 ward on how to provide or
coordinate care for him/her.
I have an inventory of
25 important papers and records
of my ward.
I maintain a list of my ward’s
medical information including
26 doctors, hospitals, past health
conditions and current
medications.

I maintain a list of emergency

contact information and
27
distribute them to family and
friends.
 I was taught on how to
correctly care for my
28 ward/loved one including
lifting, transferring, or skin
care.
I am interested in home care
29
work in general
I talk about my feelings by
attending a support group,
30
talking to a friend or seeking
counseling.
I assess my own limits
emotionally, financially,
31 physically and spiritually to
help me determine if I need
help.
I take care of myself so that I
32
can care for my ward.
I have someone to help me
33
care for my ward/love d one.
I avail of government
34 entitlements such as discounts
and free movies for my ward
Values
My loved one/ward deserve all
36
the care due him/her.
I am committed to provide
37
care for my ward/loved one.

Rating Explanation/Remarks
38 On a scale of 1 to 5, with 1 being "not
stressful" to 5 being "extremely
stressful," please rate your current
level of stress.
39 On a scale of 1 to 5, with 1 being "not
motivated" to 5 being "extremely
motivated," please rate your current
level of motivation as caregiver of
your loved one/ward.
40 On a scale of 1 to 5, with 1 being "not
cooperative" to 5 being "extremely
cooperative," please rate your
ward/loved one with care given
him/her.