* 1. How old are you?

* 2. Are you:

* 3. Please tick which postcode area you live in:

* 4. Please rate the following

  Excellent Very Good Good Moderate Poor
How would you rate your overall health?
How would you rate your physical health?
How would you rate your emotional and mental health?

* 5. Do you experience loneliness or social isolation?

* 6. Which of the following are important to you for well-being? (Please tick more than one box if applicable) 

* 7. Are you aware of any services in your area under the following headings? (Please tick more than one box if applicable) 

* 8. Do you avail of any of the above services?

* 9. If you answered YES to question 8, please specify which services you do avail of:

* 10. If you answered NO to question 8, please specify why you do not avail of these services:

* 11. Are you aware of any of the following organisations providing services in your area? (Please tick more than one box if applicable) 

* 12. Are there activities in your area for: (Please tick more than one box if applicable) 

* 13. If the following services were in your area would you avail of them? (Please tick more than one box if applicable) 

* 14. If there was a health and well-being project in your area would you be willing to volunteer in it?

* 15. Do you have any other comments or feedback about the areas covered in this survey?

T