Healthy Homes Survey (A)

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* 1. In general would you say your health is?

Excellent

Very Good

Good

Fair

Poor

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* 2. Compared to one year ago, how would you rate your health in general?

Much better than a year ago

Somewhat better than a year ago

About the same as one year ago

Somewhat worse now than one year ago

Much worse than one year ago

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* 3. Do you have any long term illness, health problem or disability which limits your daily activities?

Yes

If yes, please write the conditions

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* 4. Which of the following health problems or conditions have you experienced in the last 3 months?

	No Problem	Minimal Problem	Mild Problem	Moderate Problem	Moderately Severe Problem	Severe Problem	Very Severe Problem
Asthma	Asthma No Problem	Asthma Minimal Problem	Asthma Mild Problem	Asthma Moderate Problem	Asthma Moderately Severe Problem	Asthma Severe Problem	Asthma Very Severe Problem
Eczema	Eczema No Problem	Eczema Minimal Problem	Eczema Mild Problem	Eczema Moderate Problem	Eczema Moderately Severe Problem	Eczema Severe Problem	Eczema Very Severe Problem
Allergies	Allergies No Problem	Allergies Minimal Problem	Allergies Mild Problem	Allergies Moderate Problem	Allergies Moderately Severe Problem	Allergies Severe Problem	Allergies Very Severe Problem
Cough/cold	Cough/cold No Problem	Cough/cold Minimal Problem	Cough/cold Mild Problem	Cough/cold Moderate Problem	Cough/cold Moderately Severe Problem	Cough/cold Severe Problem	Cough/cold Very Severe Problem
Depression/Anxiety	Depression/Anxiety No Problem	Depression/Anxiety Minimal Problem	Depression/Anxiety Mild Problem	Depression/Anxiety Moderate Problem	Depression/Anxiety Moderately Severe Problem	Depression/Anxiety Severe Problem	Depression/Anxiety Very Severe Problem

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* 5. How many times have you visited the following services in the last 3 months?GP -

	Not at All	1-2 times	3-4 times	5-6 times	7-8 times	9-10 times	10+ times
GP - fixed appointment	GP - fixed appointment Not at All	GP - fixed appointment 1-2 times	GP - fixed appointment 3-4 times	GP - fixed appointment 5-6 times	GP - fixed appointment 7-8 times	GP - fixed appointment 9-10 times	GP - fixed appointment 10+ times
GP - in an emergency	GP - in an emergency Not at All	GP - in an emergency 1-2 times	GP - in an emergency 3-4 times	GP - in an emergency 5-6 times	GP - in an emergency 7-8 times	GP - in an emergency 9-10 times	GP - in an emergency 10+ times
Hospital - fixed appointment	Hospital - fixed appointment Not at All	Hospital - fixed appointment 1-2 times	Hospital - fixed appointment 3-4 times	Hospital - fixed appointment 5-6 times	Hospital - fixed appointment 7-8 times	Hospital - fixed appointment 9-10 times	Hospital - fixed appointment 10+ times
A&E	A&E Not at All	A&E 1-2 times	A&E 3-4 times	A&E 5-6 times	A&E 7-8 times	A&E 9-10 times	A&E 10+ times

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* 6. Below are some statements about your thoughts and feelings. Please tick the box that best describes your experience of each over the last 2 weeks?

	None of the time	Rarely	Some of the time	Often	All of the time
I've been feeling optimistic about the future	I've been feeling optimistic about the future None of the time	I've been feeling optimistic about the future Rarely	I've been feeling optimistic about the future Some of the time	I've been feeling optimistic about the future Often	I've been feeling optimistic about the future All of the time
I've been feeling useful	I've been feeling useful None of the time	I've been feeling useful Rarely	I've been feeling useful Some of the time	I've been feeling useful Often	I've been feeling useful All of the time
I've been feeling relaxed	I've been feeling relaxed None of the time	I've been feeling relaxed Rarely	I've been feeling relaxed Some of the time	I've been feeling relaxed Often	I've been feeling relaxed All of the time
I've been feeling interested in other people	I've been feeling interested in other people None of the time	I've been feeling interested in other people Rarely	I've been feeling interested in other people Some of the time	I've been feeling interested in other people Often	I've been feeling interested in other people All of the time
I've had energy to spare	I've had energy to spare None of the time	I've had energy to spare Rarely	I've had energy to spare Some of the time	I've had energy to spare Often	I've had energy to spare All of the time
I've been dealing with problems well	I've been dealing with problems well None of the time	I've been dealing with problems well Rarely	I've been dealing with problems well Some of the time	I've been dealing with problems well Often	I've been dealing with problems well All of the time
I've been thinking clearly	I've been thinking clearly None of the time	I've been thinking clearly Rarely	I've been thinking clearly Some of the time	I've been thinking clearly Often	I've been thinking clearly All of the time
I've been feeling good about myself	I've been feeling good about myself None of the time	I've been feeling good about myself Rarely	I've been feeling good about myself Some of the time	I've been feeling good about myself Often	I've been feeling good about myself All of the time
I've been feeling close to other people	I've been feeling close to other people None of the time	I've been feeling close to other people Rarely	I've been feeling close to other people Some of the time	I've been feeling close to other people Often	I've been feeling close to other people All of the time
I've been feeling confident	I've been feeling confident None of the time	I've been feeling confident Rarely	I've been feeling confident Some of the time	I've been feeling confident Often	I've been feeling confident All of the time
I've been able to make up my own mind about things	I've been able to make up my own mind about things None of the time	I've been able to make up my own mind about things Rarely	I've been able to make up my own mind about things Some of the time	I've been able to make up my own mind about things Often	I've been able to make up my own mind about things All of the time
I've been feeling loved	I've been feeling loved None of the time	I've been feeling loved Rarely	I've been feeling loved Some of the time	I've been feeling loved Often	I've been feeling loved All of the time
I've been interested in new things	I've been interested in new things None of the time	I've been interested in new things Rarely	I've been interested in new things Some of the time	I've been interested in new things Often	I've been interested in new things All of the time
I've been feeling cheerful	I've been feeling cheerful None of the time	I've been feeling cheerful Rarely	I've been feeling cheerful Some of the time	I've been feeling cheerful Often	I've been feeling cheerful All of the time

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* 7. What is Your Gender?

Male

Female

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* 8. What is Your Age?

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

Healthy Homes Survey (A)

Question Title

* 1. In general would you say your health is?

Question Title

* 2. Compared to one year ago, how would you rate your health in general?

Question Title

* 3. Do you have any long term illness, health problem or disability which limits your daily activities?

Question Title

* 4. Which of the following health problems or conditions have you experienced in the last 3 months?

Question Title

* 5. How many times have you visited the following services in the last 3 months?GP -

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* 6. Below are some statements about your thoughts and feelings. Please tick the box that best describes your experience of each over the last 2 weeks?

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* 7. What is Your Gender?

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* 8. What is Your Age?

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* 9. What is your Ethnicity?

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* 10. Postcode