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Aging in Place: Senior Needs Assessment Survey Template

Assess support, daily challenges, and home safety for adults 60+ in your community. Customize this aging in place survey to plan programs, resources, and care.

What's Included

AI-Powered Questions

Intelligent follow-up questions based on responses

Automated Analysis

Real-time sentiment and insight detection

Smart Distribution

Target the right audience automatically

Detailed Reports

Comprehensive insights and recommendations

Sample Survey Items

Q1
Dropdown
Which of the following best describes where you live now?
  • Single-family home
  • Apartment or condo
  • Mobile/manufactured home
  • Independent senior living community
  • Assisted living or similar
  • Other
  • Prefer not to say
Q2
Opinion Scale
How easy or difficult is it for you to live independently in your home today?
Range: 1 – 10
Min: Very difficultMax: Very easy
Q3
Multiple Choice
In the past 30 days, which tasks have been hard to do at home? Select all that apply.
  • Climbing stairs
  • Bathing or showering
  • Cooking or meal preparation
  • House cleaning or laundry
  • Managing medications
  • Grocery shopping
  • Transportation to appointments
  • Using technology or the internet
  • None of these
Q4
Multiple Choice
Which home modifications or devices do you currently use? Select all that apply.
  • Grab bars or handrails
  • Shower chair or bench
  • Ramps or no-step entry
  • Stair lift
  • Medical alert button or wearable
  • Smart doorbell or camera
  • None of these
Q5
Matrix
Today, how easy or difficult are the following health-related tasks for you?
RowsVery difficultSomewhat difficultNeither easy nor difficultSomewhat easyVery easy
Scheduling doctor or clinic visits•••••
Managing medications on time•••••
Getting transportation to care•••••
Understanding care instructions•••••
Coordinating between different providers•••••
Q6
Multiple Choice
Who helps you at least once a month? Select all that apply.
  • Spouse or partner
  • Adult child
  • Other family member
  • Neighbor or friend
  • Paid home care aide
  • Community volunteer
  • No one
Q7
Rating
How affordable are your current supports or services (if any)?
Scale: 11 (star)
Min: Not affordableMax: Very affordable
Q8
Opinion Scale
How comfortable are you using a phone, tablet, or computer for health tasks?
Range: 1 – 10
Min: Not at allMid: ModeratelyMax: Very
Q9
Ranking
Please rank these improvements from most to least helpful for staying in your home.
Drag to order (top = most important)
  1. Help with housekeeping
  2. Transportation services
  3. Meal delivery
  4. Medication management tools
  5. Home safety upgrades
  6. Social activities or companionship
  7. Telehealth or virtual visits
Q10
Long Text
In your own words, what support would help you most to remain in your home?
Max 600 chars
Q11
Dropdown
What is your age?
  • 60–64
  • 65–69
  • 70–74
  • 75–79
  • 80–84
  • 85+
  • Prefer not to say
Q12
Multiple Choice
Gender
  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
Dropdown
Where do you live?
  • North America
  • Europe
  • Asia-Pacific
  • Latin America
  • Middle East/North Africa
  • Sub-Saharan Africa
  • Other/Prefer not to say
Q14
Multiple Choice
Do you live alone?
  • Yes
  • No
  • Prefer not to say
Q15
Dropdown
Highest level of education completed
  • Less than high school
  • High school or equivalent
  • Some college or trade school
  • Associate degree
  • Bachelor's degree
  • Graduate or professional degree
  • Prefer not to say
Q16
Multiple Choice
Current employment status
  • Retired
  • Working full-time
  • Working part-time
  • Homemaker or caregiver
  • Unable to work or long-term disability
  • Unemployed and looking
  • Prefer not to say
Q17
Multiple Choice
Attention check: To show you are paying attention, please select "Yes".
  • Yes
  • No
Q18
Chat Message
Welcome! This survey takes about 7 minutes. Please answer based on your situation today.
Q19
Long Text
Is there anything else you would like to share about your situation or needs for aging in place?
Max 600 chars
Q20
AI Interview
AI Interview: 2 Follow-up Questions on aging in place
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q21
Chat Message
Thank you for your time and insights. Your responses will help improve supports for aging in place.

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