Senior Healthcare Needs Assessment Survey

Objective: To understand your current healthcare situation, identify any unmet needs, and ensure you have access to the appropriate services and support.

Full Name

Date of birth

Email *

Section 1: Referrals & Specialized Care

If you selected Other, please specify:

Section 2: Medical Supplies & Equipment (DME)

If you selected Other, please specify DME that you need:

Section 3: Routine Health Checks

When was your most recent vision (eye) exam?

Within the last year

1-3 years ago

More than 3 years ago

Never

When was your most recent hearing exam?

Within the last year

1-3 years ago

More than 3 years ago

never

Do you have denture(s) (also known as "fake teeth")?

Yes

Section 4: Primary Care Physician (PCP)

How often do you usually go to your primary care doctor?

When you have an appointment, how long is the typical wait time at the office before you see the doctor?

Less than 15 minutes

15-30 minutes

30-60 minutes

More than 60 minutes

Section 5: Upcoming Appointments & Logistics

Do you need to be accompanied when you visit the doctor?

Yes

Do you have any medical appointments scheduled in the next 2 months?

Yes

If yes, please answer the following for your upcoming appointment(s):

Name of doctor, address and your upcoming appointment day(s)

Have you seen this doctor or visited this facility before?

Yes

How long does a typical appointment take from start to finish?

Are there certain times of day that are best for you to travel to avoid heavy traffic?

Section 6: General Health & Functional Status

If you selet other, please specify the device

Do you have any significant challenges with your vision, speech, or hearing that we should be aware of?

Are there any behavioral concerns (like memory issues or changes in mood) that we should know about?

FOR CARE COORDINATOR USE ONLY

When arranging new services (e.g., Adult Day Center, PT, Podiatry):

Confirm the provider accepts MassHealth.
Call the provider to confirm they have staff who speak the senior's preferred language.
Perform a Google search to check provider reviews.
Prioritize providers located near the senior's home ZIP code.