Page 12
7/77/777 – Not asked
8/88/888 = Donot know, won’t answer
9/99/999 = Not applicable
Hughes Hall Project for Later LifeFollow up survey
Name: ______
Address: ______
Card / [1]
Project number / []
Date / [//]
List / [ ]
Age / []
Sex / Male…….1
Female…..2 / []
Interview code / []
Observer code: If no observer, code = 00 / []
GP Code / []
Introduction and explanation of visit
First of all, I'd like to ask you for some personal details.
1. / What is your full name?
/ 0. Error
1. Right / []
2 / Date of Birth?
/ 0. Error
1. Right / []
3 / Age? / 0. Error
1. Right / []
Code 9 if prompted by relative.
4. / Could you tell me how thinks have been for you in the past year?
Has anything important happened?
Have there been any changes in your family?
How has your health been?
5. Marital Status?
a. / Has your marital status changed in the last 12 month? / No..0
Yes..1 / []
b. / Current marital status: / 1. Married
2. Widowed
3. Separated/Divorced
4. Single
5. Other (specify) / []
6. Residency
a. / Have you moved house in the last 12 months? / No..0
Yes..1 / []
If still in same accommodation code 9 from (b) - (e)
If move in last 12 month:
b. / Why did you move to this address?
Code: no=0, yes=1 / To be near relative(s)
Bereavement
Ill health/disability
Smaller/more convenient house
Other reason (specify) / []
[]
[]
[]
[]
c / What type of accommodation is this? / 1. House/flat/granny flat
2. Warden controlled
3. Council residential home
4. Private residential home
5. Long stay hospital
6. Other (Specify) ______/ [ ]
d. / Is this house/flat owned or rented? / 1. Owned
2. Council rented
3. Private rented
4. Other (Specify) ______/ [ ]
e / Who is head of the household? / 1. Respondent or spouse
2. Sibling
3. Child
4. Other (specify) ______/ [ ]
Ask all:
f / Does anyone live here with you?
If lives alone, code 0 here,
Code 9 for (e) and (f) and proceed to Q15. / 0. Alone
1. With others / [ ]
g. / Who lives here with you?
Record numbers in each category. / Spouse
Siblings
Children
In laws
Grandchildren
Others (specify) ______
Add up numbers / [ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
h. / Is there anyone who lives with you who is frail and unwell and needs your help with day-to-day tasks? / 0. No
1. Yes / [ ]
di / Do you have a telephone? / 0. No
1. Yes / [ ]
7. Children if applicable:
a. / At the last interview you told us that you had children of whom where living in or near Cambridge. Is this correct or have there been changes?
Code number of living children
Code number living in Cambridge / [ ]
[ ]
If no children code 9 or 99 from (b)-(e)
b. / Can you tell me that present marital status of your children living locally?
Code numbers. / Single dgtrs….
Married dgtrs..
Single sons…
Married sons… / [ ]
[ ]
[ ]
[ ]
c. / Has there been any change in the amount of contact you have with your children? / No change….0
Less contact overall….1
More contact overall….2 / [ ]
d. / Of all your children, which one do you have the most contact with?
Code: 0=no, 1=yes / Single dgtr…1
Married dgtr..2
Single son….3
Married son…4 / [ ]
[ ]
[ ]
[ ]
If no contact with any children code 0 and 9 for (e)
e. / How often are you in contact with him/her? / No contact……………0
Daily…………..…….1
At least twice weekly..2
Weekly……………….3
At least fortnightly……4
monthly…………….....5
Less frequently……….6 / [ ]
8. Grandchildren
a. / How many grandchildren do you have living or near Cambridge at present?
If no local adult GC, code 00 here, code 9 for (b) (c). / Number……….. / [ ]
b. / Has there been any change in the amount of contact you have with your grandchildren in Cambridge? / No change….0
Less contact overall….1
More contact overall….2 / [ ]
c. / Of all your grown-up grandchildren, which one do you have most contact with? How often are you in contact with him/her? / No contact…………..0
Daily…………..…….1
At least twice weekly..2
Weekly……………….3
At least fortnightly……4
At least monthly……...5
Less frequently……….6 / [ ]
10. Other Relatives
a. / What about contact with other adult relatives living in or near Cambridge?
Code numbers where there has been contact in last 12 months..
If no adult relatives code 9 for (b). / Brothers………..
Sisters………….
Nephews………
Nieces…………
Others(specify)… / [ ]
[ ]
[ ]
[ ]
[ ]
b. / Of all your relatives, which one do you have most contact with? How often are you in contact with him/her? / No contact…………..0
Daily…………..…….1
At least twice weekly..2
Weekly……………….3
At least twice monthly..4
At least monthly……...5
Less frequently……….6 / [ ]
Card [5]
10. Friends
a. / Have there been any changes in the amount of contact you have with friends living in or near Cambridge?
If no local friends, code 9. / No change….0
Less contact overall….1
More contact overall….2 / [ ]
b. / Of all your friends in Cambridge or elsewhere, which one do you have most contact with? How often are you in contact with him/her?
If no friends anywhere, code 9. / No contact…………..0
Daily…………..…….1
At least twice weekly..2
Weekly……………….3
At least fortnightly……4
monthly………….…...5
Less frequently……….6 / [ ]
11. Social contact in previous week
a. / I would like to get an idea of how you have spent the last week, what you have done, who you have seen, spoken to on the phone or been in correspondence with.
For example, were you in contact with any of your children/friends/neighbours last week?
Ask about each of the previous 7 days or each category of people according to which is most appropriate. Prompt as necessary.
If no children, grandchildren, friends, Etc, code 99.
If no telephone code 99 for phone calls.
Children: / Visits……
Phone call…….. / [ ]
[ ]
Grandchildren: / Visits……
Phone call…….. / [ ]
[ ]
Other relatives: / Visits……
Phone call…….. / [ ]
[ ]
Friends: / Visits……
Phone call…….. / [ ]
[ ]
Neighbours: / Visits……
Phone call…….. / [ ]
[ ]
b. / Did you have any contact with any clubs or organisations in the past week?
Over 60's Club / [ ]
Other social club / [ ]
Church / [ ]
Church group / [ ]
Voluntary work / [ ]
Other (specify) ______/ [ ]
c. / Did you have any contact with any of the services in the past week?
Code number of contacts during past 7 days / Home help
Community nurse
Meals on wheels
Day centre…..
Day hospital… / [ ]
[ ]
[ ]
[ ]
[ ]
d. / Was this a typical week? Would you normally see this number of people – children, other relatives, friends – or would you normally see more or fewer? / Fewer…………..0
Same……..…….1
More…………...2 / []
13.Usual contact with neighbours, clubs, church and services
Ask appropriately and code for all respondents whether or not previous week was typical.
a. / How much contact do you normally have with neighbours? / No contact………..0
Occasional chats…1
Regular chats…….2
Close/do favours….3 / [ ]
b. / Do you normally attend any clubs or groups or do any voluntary work?
If yes: Have you participated in the past month?
Code no=0, yes=1.
Over 60's Club / [ ]
Other social club / [ ]
Church group / [ ]
Voluntary work / [ ]
Other (specify) ______/ [ ]
c. / Have you attended church in the last year? / Not at all………..0
Occasionally……1
Regularly….…….2 / [ ]
d. / Have you seen a community nurse in the past month?
Code number of visits in last month
None= 0, Maximum = 6. / [ ]
e. / Do attend a day centre or day hospital? / Day centre…..
Day hospital… / [ ]
[ ]
13. PHYSICAL HEALTH
a. / How would you rate your physical health at present? / 1. Very good
2. Good
3. Fair
4. Poor
5. Very poor / [ ]
b. / What particular difficulties do you have?
c. / In particular, have you suffered from any of the following difficulties in the last month?
Code No=0, Yes = 1.
Code “Yes” only if disability present for one month and has interfered with daily tasks. / Poor vision (with spectacles)
Poor hearing (with hearing aid) Arthritis/ rheumatism
Back pain
Chest pain
Shortness of breath
Weakness in arm or leg
Unsteady on feet
Falls / [ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
d. / Have you seen your G.P in the last year?
Round up to nearest month last visit. / Months / [ ]
e. / Were you admitted to any hospital in last year? / No…0
Yes…1 / [ ]
14. ACTIVITIES OF DAILY LIVING
Now I'd like to ask you some questions about how you cope with day-to-day tasks.
(a) / How do you manage with using a telephone i.e. looking up numbers, dialling etc?
0 Telephones independently – looks up numbers, dials etc.
1 Dials a few well-known numbers only.
2 Answers telephone but does not dial.
3 Cannot use telephone at all.
9 No telephone within easy access. / [ ]
(b) / How do you manage with shopping?
0 Takes care of all or nearly all shopping independently
1 Shops independently for small purchases only.
2 Needs to be accompanied on any shopping trip.
3 Does not shop at all / [ ]
Who helps? / [ ]
(c) / How do you manage with preparing meals?
0 Prepares all or nearly all meals independently.
1 Prepares snacks only or heats up meals prepared by others.
2 All meals and snacks must be prepared by others.
9 Meals have always been prepared by spouse or others. / [ ]
Who helps? / [ ]
(d) / How do you manage with housework?
0 Independent apart from occasional help with heavy work.
1 Performs only light daily tasks e.g. dish washing, dusting.
2 All housework must be done by others.
9 Housework has always been done by spouse or other. / [ ]
Who helps? / [ ]
Code:
Nobody/none required .. 00 Home help ………………08
Spouse …………………01 Meals on wheels ………..09
Daughter ……………….02 Community nurse ………10
Daughter – in – law ……03 Chiropodist ……………..11
Son ……………………..04 Warden …………………12
Son – in – law ………….05 Other (specify) ………… 13
Other relative …………..06
Friend/Neighbour ……..07
For “Who helps?”, use only these codes. Do not use 99.
0 Independent apart from occasional help with heavy work.
1 Lauders only small items, e.g. stockings, underwear
2 All laundry must be done by others
9 Laundry has always been done by spouse or others / [ ]
Who helps? / [ ]
(f) / How do you manage with walking?
0 Walks around town, suburb or village
1 Walks no further than one block away
2 Walks no further than gate
3 Walks only within house
4 Takes no more than a few steps / [ ]
(h) / Do you use a walking stick or other aid?
0 Independent
1 Walking stick(s)
2 Frame/tripod
3 Wheelchair
4 Other person / [ ]
(i) / How do you manage with bathing or showering?
0 Independent in bath, shower or sponge-wash
1 Needs help getting in or out of bath or shower
2 Can wash face and hands only
3 Needs major assistance / [ ]
Who helps? / [ ]
Code: Nobody/none required .. 00 Home help ………………08
Spouse …………………01 Meals on wheels ………..09
Daughter ……………….02 Community nurse ………10
Daughter – in – law ……03 Chiropodist ……………..11
Son ……………………..04 Warden …………………12
Son – in – law ………….05 Other (specify) ………… 13
Other relative …………..06
Friend/Neighbour ……..07
For “Who helps?”, use only these codes. Do not use 99.
0 Attends to grooming independently
1 Needs minor assistance, e.g. cutting toenails
2 Needs moderate assistance, e.g. shaving, brushing hair
3 Needs major assistance. / [ ]
Who helps? / [ ]
(k) / How do you manage with dressing or undressing?
0 Dresses and undresses independently
1 Needs minor assistance, e.g. tying shoelaces, buttons
2 Needs moderate assistance
e.g. shoes, socks, arms in sleeves, selecting clothes
3 Needs major assistance / [ ]
Who helps? / [ ]
(l) / How do you manage with getting to the toilet on time?
0 Always gets to the toilet on time
1 Rare (weekly at most) accidents
2 Accidents more than once a week
3 No control of bladder or bowels / [ ]
Who helps? / [ ]
(m) / How do you manage with taking medicines?
0 Responsible for taking medicines in correct dose at correct time.
1 Medication must be put out in advance by others
2 Medication must be administered by others
9 Takes no medication at present / [ ]
Who helps? / [ ]
(n) / Do you think that you need more help than you are getting at the moment?
0 No
1 Yes / [ ]
Code:
Nobody/none required .. 00 Home help ………………08
Spouse …………………01 Meals on wheels ………..09
Daughter ……………….02 Community nurse ………10
Daughter – in – law ……03 Chiropodist ……………..11
Son ……………………..04 Warden …………………12
Son – in – law ………….05 Other (specify) ………… 13
Other relative …………..06
Friend/Neighbour ……..07
For “Who helps?”, use only these codes. Do not use 99.
Card [3]
15. Mental state examination.I know you did well on the test of memory and concentration last time. I wonder would you be prepared to do it again as we are interested in seeing whether there has been an overall change in the pattern of performance as a result of everyone being a year older, etc.