| 1. What best describes your living environment? |
1. Live alone |
| 2. Live with spouse |
| 3. Live with a relative or friend |
| 4. Live in residential home or sheltered accommodation |
| 5. Live in fold |
| 6. Other (please state) |
|
|
| 2. My eyesight prevents me from attending to my own needs. |
1. Strongly agree |
| 2. Agree |
| 3. Neither agree or disagree |
| 4. Disagree |
| 5. Strongly disagree |
|
|
| 3. I feel I have to be more careful because of my eyesight. |
1. Strongly agree |
| 2. Agree |
| 3. Neither agree or disagree |
| 4. Disagree |
| 5. Strongly disagree |
|
|
| 4. Please indicate any outside help you receive. |
1. Home help provided by social services |
| 2. Private home help |
| 3. Meals on wheels |
| 4. Day centre attendance |
| 5. Family or friends |
| 6. Other (please state) |
|
|
| 5. Do you receive any of the following benefits? |
1. Income support |
| 2. Attendance allowance |
| 3. Assistance with rent/rates |
| 4. Disability living allowance |
| 5. Other (please state) |
