Catalogue of Social Care Data

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

In total, how many hours do you spend each week looking after or helping this person/these people?

0-4 hours per week 1
5-9 hours per week 2
10-19 hours per week 3
20-34 hours per week 4
35-49 hours per week 5
50-99 hours per week 6
100 or more hours per week/continuous care 7
Varies under 20 hours 8
Varies 20 hours or more 9
Other 10

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

If you (and your spouse) needed help with daily activities because of sickness, frailty or disability, who would be most likely to provide help?

Son (including stepson, adopted son or son in law) 1
Daughter (including stepdaughter, adopted daughter, daughter in law) 2
Other family member 3
Friend or Neighbour (including voluntary helper) 4
Paid/professional help 5
Other, please specify 6

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY – To be asked to a family member or friend

I will now ask you some questions about how {Forenames} performs some day to day activities. Please consider each question in the context of whether there has been a change in {Forenames}’s behaviour over the past several years. Answering “Yes, a change” indicates that there has been a change in the last several years caused by cognitive
(thinking and memory) problems.

1. Problems with judgement (e.g. problems making decisions, bad financial decisions, problems with thinking)?
2. Less interest in hobbies/activities?
3. Repeats the same things over and over (questions, stories, or statements)?
4. Trouble learning how to use a tool, appliance, or gadget (e.g., VCR, computer, microwave, remote control)?
5. Forgets correct month or year?
6. Trouble handling complicated financial affairs (e.g., balancing checkbook, income taxes, paying bills)?
7. Trouble remembering appointments
8. Daily problems with thinking and/or memory?

For each of the 8 questions, the response scale is the same:
1 Yes, a change
2 No, no change
3 Don’t know

These questions relate to your independence to perform daily tasks. Are you able to do the following activities alone or is help required?

Feed myself
Bathing (e.g. shower, bath)
Grooming (e.g. brushing teeth,
shaving)
Dressing (including buttons,
zips)
Toilet use (including managing
personal hygiene)
Stairs (including with aids such
as a walking stick)
Cutting toenails

For each task:
I can do this myself
I can do this myself but with difficulty
I need help with this
I am unable to manage this

Are you able to transfer from a bed to a chair and back again independently, or is help required?

Independently
Independently but with difficulty
I need minor help (someone to be with me)
I need major help (people to physically help me), but I can sit unsupported
Unable (5)

Are you able to move on level surfaces alone or is help required?

Independently (but may use any aid, e.g. walking stick or frame), can move more than 5 yards
Independently but with difficulty (including with any aid), can move more than 5 yards
Walk with help of one person (verbal or physical), can move more than 5 yards
Using a wheelchair independently, including corners, can move more than 5 yards
Immobile or can move less than 5 yards

The following questions are about everyday activities. Please record what you have done in the last month. If you have not done an activity in the last month because you are not able to do it, then please put a “x” in “I am unable to manage this”. If you have the ability to do it, but have not done it, for example the weather has been too bad for gardening, please put an “x” in “Not applicable”

Walk around outside?
Climb stairs?
Get in and out of a car?
Walk over uneven ground?
Cross roads?
Travel on public transport?
Manage to feed yourself?
Manage to make yourself a hot drink?
Take hot drinks from one room to
another?
Do the washing up?
Make yourself a hot snack?
Manage your own money when out?
Wash small items of clothing?
Do your own housework?
Do your own shopping?
Do a full clothes wash?
Read newspapers or books?
Use the phone?
Write letters?
Go out socially?
Manage your own garden?
Drive a car?

For each task:
I can do this myself
I can do this myself but with difficulty
I need help with this
I am unable to manage this
Not applicable

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

HAVE YOU RECENTLY:
1. Been feeling perfectly well and in good health?
2. Been feeling in need of a good tonic?
3. Been feeling run down and out of sorts?
4. Felt that you are ill?
5. Been getting any pains in your head?
6. Been getting a feeling of tightness or pressure in your
7. Been having hot or cold spells?
8. Lost much sleep over worry?
9. Had difficulty staying asleep once you are off?
10. Been managing to keep yourself busy and occupied?
11. Been taking longer over the things you do?
12. Felt on the whole you were doing things well?
13. Been satisfied with the way you’ve carried out your task?
14. Felt that you are playing a useful part in things?
15. Felt capable of making decisions about things?
16. Felt constantly under strain?
17. Been able to enjoy your normal day-to-day activities?
18. Been getting edgy and bad-tempered?
19. Been getting scared or panicky for no good reason?
20. Found everything getting on top of you?
21. Been thinking of yourself as a worthless person?
22. Felt that life is entirely hopeless?
23. Been feeling nervous and strung-up all the time?
24. Felt that life isn’t worth living?
25. Thought of the possibility that you might make away with yourself?
26. Found at times you couldn’t do anything because your nerves were too bad?
27. Found yourself wishing you were dead and away from it all?
28. Found that the idea of taking your life kept coming into your mind?

For all questions the following response scale is used:
Better than usual 1
Same as usual 2
Worse than usual 3
Much worse than usual 4

OR

Not at all 1
No more than usual 2
Rather more than usual 3
Much more than usual 4

DEPENDING ON WHICH IS APPROPRIATE

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Addenbrooke’s Cognitive Examination
(ACE) (via iPAD)

If willing, participant will complete Addenbrooke’s Cognitive Examination.

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Participant is measured and weighed.

If willing/possible measurements and weight recorded

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Chair raise test

Results of chair raise test

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Balance and co-ordination tests

Results of balance and co-ordination tests

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Walking speed test

Results of walking speed test

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Hand grip test

Results of hand grip test

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Lung function test

Results of lung function test

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Cognitive tests

Results of cognitive test

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Which of the letters on the SHOWCARD A represents your total net household income? Please include your own and your partner’s earned income (after deduction for income tax and national insurance), any state benefits and any other sources of income such as pension, interest and rental income. Please also include contributions from other members of your household (such as children). Please choose the period (annual, monthly or weekly) that is most convenient for you to use. Then, find the amount in pounds which represents your net household income and state the corresponding letter.

Annual Monthly Weekly
Less than £6,000 A =1 less than £500 Less than £116
£6,000 – £7,999 B = 2 £500 – £666 £116 – £153
£8,000 – £9,999 C = 3 £667 – £833 £154 – £192
£10,000 – £11,999 D= 4 £834- £999 £193 – £230
£12,000 – £14,999 E = 5 £1,000 – £1,249 £231 – £288
£15,000 – £17,999 F = 6 £1,250 – £1,499 £289 – £346
£18,000 – £20,999 G = 7 £1,500 – £1,749 £347 – £403
£21,000 – £23,999 H = 8 £1,750 – £1,999 £404 – £461
£24,000 – £26,999 I = 9 £2,000 – £2,249 £462 – £519
£27,000 – £29,999 J = 10 £2,250 – £2,499 £520 – £576
£30,000 – £39,999 K = 11 £2,500 – £3,333 £577 – £769
£40,000 – £79,999 L = 12 £3,334 – £6,666 £770 – £1,538
£80,000 or more M = 13 £6,667 or more £1,539 or more

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

On your present household income do you find

That it’s really quite hard to manage?
That you manage fairly well?
That you manage comfortably?

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Have you or your family had to go without things you really needed in the last year because you were short of money?

Yes, often
Yes, sometimes
No

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Have you found you have been unable to pay the bills in the last year because you were short of money?

Yes, often
Yes, sometimes
No

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Thinking of the next ten years, how financially secure do you feel? READ OUT…

Secure
Fairly secure
Neither secure nor insecure
Fairly insecure
Insecure

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

If you sold all the assets you own in your household, for example, your house, car, caravan, and jewelry, cashed in your savings and investments, and paid off any debts you have (including your mortgage), how much money do you think you would have? Please find the amount in pounds which represents the total amount and state the corresponding letter

Total wealth
A=1 Less than £12,500
B=2 £12,500 to £39,999
C=3 £40,000 to £99,999
D=4 £100,000 to £199,999
E=5 £200,000 to £299,999
F=6 £300,000 to £399,999
G=7 £400,000 to £499,999
H=8 £500,000 to £599,999
I=9 £600,000 to £699,999
J=10 £700,000 to £799,999
K=11 £800,000 to £899,999
L=12 £900,000 to £999,999
M=13 £1,000,000 or £1,999,999
N=14 £2,000,000 or more
15 Refused to answer

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Is there anyone LIVING WITH YOU who is sick, frail, or has a disability whom you look after or give special help to (for example, a sick, disabled, or older relative/husband/wife/ friend, etc.)?

No
Yes

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Who do you look after or help that lives with you?

List all that apply
Wife/Husband/Partner
Mother/mother-in-law
Father/father-in-law
Son/daughter (incl. stepchildren)
Grandchild/ren
Friend
Other

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

In total, how many hours do you spend each week looking after or helping these people?

0-4 hours per week 1
5-9 hours per week 2
10-19 hours per week 3
20-34 hours per week 4
35-49 hours per week 5
50-99 hours per week 6
100 or more hours per week/continuous care 7
Varies under 20 hours 8
Varies 20 hours or more 9
Other 10

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Do you provide some regular service or help for any sick, disabled or older person NOT LIVING WITH YOU?

No
Yes

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Who do you help that does not live with you?

Volunteer (e.g. hospice/Samaritans)
Mother/mother-in-law/stepmother
Father/father-in-law/stepfather
Son/daughter/stepson/stepdaughter
Aunt/uncle
Sister/brother
Neighbour/s
Friend/s
Ex-Wife/Ex-Husband/Ex-Partner
Other

Since the age of 60 years, have you ever been told by a doctor that you have any of the following medical conditions? If yes, what year were you diagnosed?
Please only include conditions or events diagnosed by a doctor.

COPD (chronic obstructive pulmonary disease)
Emphysema
Angina
Heart attack (myocardial infarct/coronary thrombosis)
Heart failure
High blood pressure (hypertension)
Orthostatic or postural hypotension (blood pressure too low when you stand up)
Stroke
Diabetes
Atrial fibrillation
Osteoporosis
Osteoarthritis
Eye trouble which requires treatment:
Cataracts
Glaucoma
Age-related macular degeneration
Parkinson’s Disease
Cognitive impairment:
Vascular dementia
Alzheimer’s disease
Mild cognitive impairment
Other – Please specify:

These questions relate to your independence to perform daily tasks. Are you able to do the following activities alone or is help required?

Feed myself
Bathing (e.g. shower, bath)
Grooming (e.g. brushing teeth,
shaving)
Dressing (including buttons,
zips)
Toilet use (including managing
personal hygiene)
Stairs (including with aids such
as a walking stick)
Cutting toenails

For each task:
I can do this myself
I can do this myself but with difficulty
I need help with this
I am unable to manage this

Are you able to transfer from a bed to a chair and back again independently, or is help required?

Independently
Independently but with difficulty
I need minor help (someone to be with me)
I need major help (people to physically help me), but I can sit unsupported
Unable (5)

Are you able to move on level surfaces alone or is help required?

Independently (but may use any aid, e.g. walking stick or frame), can move more than 5 yards
Independently but with difficulty (including with any aid), can move more than 5 yards
Walk with help of one person (verbal or physical), can move more than 5 yards
Using a wheelchair independently, including corners, can move more than 5 yards
Immobile or can move less than 5 yards

The following questions are about everyday activities. Please record what you have done in the last month. If you have not done an activity in the last month because you are not able to do it, then please put a “x” in “I am unable to manage this”. If you have the ability to do it, but have not done it, for example the weather has been too bad for gardening, please put an “x” in “Not applicable”

Walk around outside?
Climb stairs?
Get in and out of a car?
Walk over uneven ground?
Cross roads?
Travel on public transport?
Manage to feed yourself?
Manage to make yourself a hot drink?
Take hot drinks from one room to
another?
Do the washing up?
Make yourself a hot snack?
Manage your own money when out?
Wash small items of clothing?
Do your own housework?
Do your own shopping?
Do a full clothes wash?
Read newspapers or books?
Use the phone?
Write letters?
Go out socially?
Manage your own garden?
Drive a car?
Use the internet for shopping?

For each task:
I can do this myself
I can do this myself but with difficulty
I need help with this
I am unable to manage this
Not applicable

Do you receive help with any of the daily tasks and everyday activities listed in questions 18 and 21 [about completion of ADLs/IADLs]?

Yes
No

Thinking about a typical week, who has helped you with the type of activities listed in questions 18 and 21 and how many hours have they helped you with these tasks?

Husband/Wife/Partner
Children
Grandchildren
Sibling
Other relative
Friends or neighbours
Home care worker/ home help/ personal assistant
A member of the reablement / intermediate care staff team
Voluntary helper
Warden / Sheltered housing manager
Cleaner
Council’s handyman
Member of staff at the care/nursing home
Other – please specify

For each type of helper:
No help
Less than one hour
1-4 hours
5-9 hours
10-19 hours
20-49 hours
50+ hours

Do you live in a care home?

Yes
No

Thinking about a typical week, who have you helped with the type of activities listed in questions 18 and 21 [list of ADLs/IADLs] and how many hours have you helped others with these tasks? Please do not include occasional errands or odd jobs.

Husband/Wife/Partner
Children
Grandchild
Siblings
Other relative
Friend or neighbours
Other – please specify

For each type of person:
No help
Less than one hour
1-4 hours
5-9 hours
10-19 hours
20-49 hours
50+ hours

Have you wanted to use any of the following services in the last 6 months and if so, how long did you have to wait between first trying to get an appointment and getting an appointment or receiving care (personal care)?

GP healthcare
Dentist healthcare
Chiropodist or podiatrist healthcare
Exercise classes including yoga, Pilates, gym
Occupational therapist or physiotherapist
Community nurse
Hospital nurse
Counselling
Other mental health care services
Personal care (e.g. bathing, showering, dressing, toileting)
Other – please specify

For each service listed:
Less than 2 weeks
From 2 weeks to 6 months
Over 6 months
Did not want to use service

Are you receiving the following?

Participant ticks the options which apply out of:
Attendance Allowance
Carer’s Allowance
Pension Credit
Council Tax Reduction
State Pension
Housing Benefit
Winter Fuel Payment
Cold Weather Payments
None of these
Prefer not to say

Do you have lasting power of attorney (LPA) in place for?

Select which applies:
Health and care
Financial decisions

Does your household currently receive any food from any of the following? Please tick all that apply

Food banks
Food provided by community organisations/allotment schemes
Meals on wheels
Food from faith-based organizations
Food from friends/neighbours
Food from family (not living in the home)
Food from another source
No assistance required
Prefer not to say

Does your household currently receive any of the following?
Please tick all that apply.

Universal credit
Pension credit
Income support or Job Seeker’s Allowance
Working Tax Credit or Child Tax credit
Employment and Support Allowance
Statutory sick pay
Housing benefit
Council tax support or reduction
Carers allowance, Personal independence payments, or Disability Living
Allowance
No assistance received
Prefer not to say

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Are you regularly taking any medicines or tablets prescribed by a doctor?

Yes
No

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

NURSE: Enter name of medicine or drug. Ask if you can see the containers for all prescribed medicines currently being taken.

What is the frequency you take this medication?

Have you taken this medication in the last 24 hours?

Enter medication taken

Enter frequency of medication consumption

Yes/No

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Overall, how satisfied are you with your life nowadays, where 0 means ‘not at all’ and 10 means ‘completely’?

Scale: 0-10

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

How is your health in general?

1 Excellent
2 Very good
3 Good
4 Fair
5 Poor

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Seating and standing blood pressure is taken

Results of seating and standing blood pressure.

*THESE MEASURES ARE SPECIFICALLY TAKEN ABOUT PEOPLE LIVING IN NURSING HOMES ONLY

Blood sample taken

Blood sample taken

OR

Record why blood sample refused.
CODE ALL THAT APPLY.
1. Previous difficulties with venipuncture
2. Dislike / fear of needles
3. Respondent recently had blood test / health check
4. Refused because of current illness
5. Worried about HIV or AIDS
6. Other

In the last four weeks who has provided the person you live with the help they have needed. Please tick all that apply

Me Nobody-needs were not met
Husband/wife/partner
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

In the last four weeks how many hours of help has someone you lived with usually received each week?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

In the last four weeks have you needed help with personal task (washing, dressing) or domestic tasks (shopping, providing meals) because you could not manage them alone?

Yes I needed help No

In the last four weeks who has provided you with the help you have needed. Please tick all that apply

Nobody-needs were not met
Husband/wife/partner
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

In the last four weeks how many hours of help have you usually received each week?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

In the last four weeks has someone you lived with needed help with personal task (washing, dressing) or domestic tasks (shopping, providing meals) because they could not manage them alone?

Yes-someone I lived with needed help
No
Not applicable-live alone

In the last four weeks who has provided the person you live with the help they have needed. Please tick all that apply

Nobody-needs were not met
Husband/wife/partner
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

In the last four weeks how many hours of help has someone you lived with usually received each week?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

Altogether how many hours help have you received with these tasks in the last week

No help in the past week
Less than 1 hour
1-4 hours
5-9 hours
10-19 hours
20-34 hours
35-49 hours
50-99 hours
1000 hours or more

Is there anyone living with you who is sick, frail, or has a disability whom you look after or give special help to (for example, a sick, disabled, or older relative/husband/wife/friend etc.)

No
Yes

Who do you look after or help that lives with you?

Wife/husband/partner
Mother/mother-in-law
Father/father-in-law
Son/daughter
Grandchildren
Friend
other

If you (and your spouse) needed help with daily activities because of sickness, frailty or disability, who would be most likely to provide help?

Son (including stepson, adopted son or son in law)
Daughter (including stepdaughter, adopted daughter or daughter in law)
Other family member
Friends or neighbor (including voluntary helper)
Paid/professional help Other

Before the Coronavirus outbreak did you or a person you live with usually get help with regular personal tasks (washing, dressing) or domestic tasks (shopping, providing meals) that cannot be managed alone?

No help needed
No help received
Help received for myself
Help received for someone I live with

Who provided this help? Please tick all that apply

Husband/wife/partner/self
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

Altogether how many hours help have you received with these tasks in the last week

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more

Since the Coronavirus outbreak have you or someone you live with had a change in help needed and/or received?

Yes, there has been a change to the care needed or received
No change

Since the Coronavirus outbreak, how many hours help have you or someone you live with typically received each week?

0 hours. Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

Who provided this help? Please tick all that apply

“Husband/wife/partner/self
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other “

In the past month before the Coronavirus outbreak in March did you need help with personal tasks( washing, dressing) or domestic tasks (shopping, providing meals) because you could not manage them alone?

Yes I needed help No

In the past month before the Coronavirus outbreak in March, who provided you with the help you needed? Please tick all that apply.

Nobody- needs were not met Husband/wife/partner/self
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

In the month before the Coronavirus outbreak in March how many hours of help did you usually get each week ?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

In the month before the Coronavirus outbreak in March did someone you lived with need help with personal tasks (washing, dressing) or domestic tasks (shopping, providing meals) because they could not manage alone?

Yes-someone you lived with needed help
No
Not applicable-live alone

In the month before the Coronavirus outbreak in March who provided the person you live with the help they needed? Please tick all that apply.

Nobody-needs were not met
Me
My Husband/wife/partner
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other

In the month before the Coronavirus outbreak in March how many hours of help did the person you live with usually get each week?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

In the last four weeks have you needed help with personal task (washing, dressing) or domestic tasks (shopping, providing meals) because you could not manage them alone?

Yes I needed help No

In the last four weeks who has provided you with the help you have needed. Please tick all that apply

“Nobody-needs were not met
Husband/wife/partner
Son or daughter or other family member (include even if not blood related)
Friend or neighbor
Voluntary helper
Paid/professional help
Other “

In the last four weeks how many hours of help have you usually received each week?

Up to 4 hours
5-9 hours
10-19 hours
20-34 hours
35 hours or more”

In the last four weeks has someone you lived with needed help with personal task (washing, dressing) or domestic tasks (shopping, providing meals) because they could not manage them alone?

Yes-someone I lived with needed help
No
Not applicable-live alone

Can you dress and undress yourself, including putting on your shoes and socks, without aids/special items or personal help?

Yes
No, uses aids/special items only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: getting in or out of a chair?

No
Yes

Can you get in or out of a chair without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: getting in or out of bed?

No
Yes

Can you get in and out of bed without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: getting around indoors?

No
Yes

Can you get around indoors without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: using the toilet?

No
Yes
Not applicable

Can you use the toilet without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: feeding yourself, including cutting up food?

No
Yes

Can you feed yourself, including cutting up food, without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Please tell me about all the people on the list who have helped you with these tasks in the last month

No help received in past month
Husband/wife/partner
Son (including stepson, adopted son or son in law)
Daughter (including stepdaughter, adopted daughter or daughter in law)
Other family member
Friends or neighbor
Voluntary helper
Paid/professional help
Home care worker/home help/personal assistant
Member if reablement/intermediate care staff team
Occupational therapist/physiotherapist
Warden/sheltered housing manager
Cleaner
Other

Altogether how many hours help have you received with these tasks in the last week

No help in the past week
Less than 1 hour
1-4 hours
5-9 hours
10-19 hours
20-34 hours
35-49 hours
50-99 hours
1000 hours or more

Do you have difficulty with any of the following activities…: taking the right amount of medicines at the right time?

No
Yes
Not applicable (don’t take any medications)

Do you have difficulty with any of the following activities…: doing routine housework or laundry?

No
Yes
Not applicable

Do you have difficulty with any of the following activities…: preparing hot meals?

No
Yes
Not applicable

Do you have difficulty with any of the following activities…: doing paperwork and paying household bills?

No
Yes
Not applicable

Do you have difficulty with any of the following activities…: shopping for food including getting to the shops, choosing the items, carrying the items home, and then unpacking and putting the items away?

No
Yes
Not applicable

Do you have difficulty with any of the following activities…: getting out of the home, for example to go to the doctors or to visit a friend?

No
Yes
Not applicable

Please tell me about all the people on the list who have helped you with these tasks in the last month

No help received in past month
Husband/wife/partner
Son (including stepson, adopted son or son in law)
Daughter (including stepdaughter, adopted daughter or daughter in law)
Other family member
Friends or neighbor
Voluntary helper
Paid/professional help
Home care worker/home help/personal assistant
Member if reablement/intermediate care staff team
Occupational therapist/physiotherapist
Warden/sheltered housing manager
Cleaner
Other

On your present household income do you find (as a family)

That it’s really quite hard to manage
That you manage fairly well
That you mange comfortably

Is it difficult because of long term health problems for you to do any of the following activities? A) go shopping and carry a full bag of shopping in each hand? B) do heavy housework? C) prepare a hot meal

Yes
No

Is it difficult because of long term health problems for you to do any of the following activities? A) washing hands and face? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

b) bathing or showering? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

c) dressing or undressing? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

d) getting in or out of a chair ? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

e) getting to the toilet? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

f) using the toilet? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

g) feeding yourself, including cutting up food? If yes can you do it without aids or personal help?

No
Yes

Yes
No, uses aid only but no personal help
No needs personal help

The following question asks you to indicate the level of physical and mental fatigue (i.e., tiredness, exhaustion) you expect or imagine when competing each of the ten listed activities.

Leisurely walk for 30 minutes
Brisk walk for 1 hour
Light household activity for 1 hour (cleaning, cooking, dusting, baking, making beds, watering plants)
Heavy gardening or outdoor work for 1 hour (mowing [push], raking, weeding, planting)

Have you done this activity within the last month?

0 No Fatigue
1
2
3
4
5 Extreme Fatigue

1 YES
0 NO

Do you have difficulty walking for a quarter of a mile on this level?

No
Yes
Not applicable, unable to walk

Do you have difficulty walking up and down stairs?

No
Yes
Not applicable, cannot walk up and down stairs

When walking up and down a flight of 12 stairs do you need to
a) Hold on?
b) Stop for a rest?
c) Go sideways or one step at a time?

No
Some of the time
Most/all of the time

Do you have difficulty with any of the following activities…: Cutting your toenails?

No
Yes, some difficulty
Yes, a lot of difficulty

Can you cut your toenails without personal help?

Yes
No

Do you have difficulty with any of the following activities…: Bathing and/or showering (including getting into and out of the bath or shower)?

No
Yes, difficult to bath but not shower
Yes, difficult to bath and shower

Can you bath or shower without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: Washing your hands and face?

No
Yes

Can you wash your hands and face without aids or personal help?

Yes
No, uses aids only
No, uses personal help only
No needs aids and personal help

Do you have difficulty with any of the following activities…: dressing and undressing yourself?

No
Yes