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1. What is your gender?

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Male

Female

2. What is your zipcode? 3. Where do you reside? (Check all that apply)

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Independent living facility Live with family or friends

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Assisted living facility Rent an apartment

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Own a house Live alone

Rent a house

4. How long have you lived at your current address (if living in assisted/independent living facilities)?
<6 months

6 12 months

1-2 years

3-5 years

>5 years

5. If living with family or friends, how many other people reside in the place of residence? 6. What ethnicity do you identify with? 7. What race do you identify yourself with?

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Hispanic / Latino

Not Hispanic / Latino

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African American Native American

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Asian Pacific Islander

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Middle Eastern White

8. What is your country of birth?

9. Are you currently employed?

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Yes, full time No, unemployed

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Yes, informal sector No, retired

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No, homemaker No, disabled

10. Do you have health insurance? If NO, skip to question #12. 11. If YES, what kind of health insurance do you have?

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Yes

No

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AARP (supplement)

IEHP

MediCal

MediCare

Molina Healthcare / Kaiser Permanente

San Bernardino County Insurance

Other private insurance

12. Do you have a regular healthcare provider? 13. If YES, how often do you see him or her?

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Weekly

Yes

No

Annually

Twice a year

Monthly

Only when I am sick

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14. What is the highest level of education you have completed? (emphasize the number of years)

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Did not attend school Trade School

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Grades 1-6 Some College

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Grades 7-8 College Degree

Grades 9-12

15. Have you received any education outside of the United States? If NO, skip to question #17. 16. If YES, how many years did you receive education outside of the United States?

Yes

No

None

1-3

4-6

7-9

10+

17. What is your age? 18. What is your marital status?

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Divorced/Separated

Married

Single

Widowed

Living with a partner

GENERAL 19. Do you have children? If NO, skip to the next section. 20. If YES, how many do you have?

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10-50 miles Out of country 1

Yes

No

4 or more

21. How far do they live from you (if more than one, use the one living the closest)?

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0-5 miles 100+ miles

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5-10 miles Out of state

50100 miles

22. How often do you talk to any of them on the phone?

Daily Monthly 2-4 times a month Yearly

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Once a week Rarely

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Twice a month No Communication

YOUR HEALTH 23. In general, my health is:

Excellent

Very Good

Good

Fair

Poor

[Response definition: N = not during the past month, L = Less than once a week, O = Once or twice a week, T = three or more times a week] During the past month, how often have you had trouble sleeping because you: 24. Cannot get to sleep within 30 minutes 25. Wake up in the middle of the night or early morning 26. Have to get up to use the bathroom 27. Cannot breathe comfortably 28. Cough or snore loudly
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N 29. Feel too cold 30. Feel too hot 31. Had bad dreams 32. Have pain

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33. Other reasons 34. During the past month, how would you rate your sleep quality overall?

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Very good

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Fairly good

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Fairly bad

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Very bad

35. During the last six months, how would you rate your appetite?
Very good Fairly good Fairly bad Very bad Never

36. Do you eat alone?

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Sometimes

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Often

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Always

37. Do you eat with others?

Never

Sometimes

Often

Always

I am going to ask you about some of the ways you may have felt or behaved. Please tell me how often you have felt this way during the past week. [Response definition: R = Rarely or none of the time (less than 1 day), S = some or a little of the time (1-2 days), O = Occasionally or a moderate amount of time (3-4 days), A = All of the time (5-7 days)] R S O A 38. I was bothered by things that usually dont bother me. 39. I had trouble keeping my mind on what I was doing. 40. I felt depressed. 41. I felt fearful. 42. I felt lonely. 43. I felt that everything I did was an effort. 44. I felt hopeful about the future. 45. I was happy. 46. My sleep was restless. 47. I could not get going. 48. I felt neglected.

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EXPERIENCE 49. Are you familiar with any of the following terms? [Reference definition: N = not at all familiar, S = Somewhat familiar, F = Familiar, V = Very Familiar]
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N Alzheimers disease Dementia (non-specific) Parkinsons disease Stroke Mild Cognitive Impairment

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This section describes some experiences or feelings you or a family member may have had at some point in life. Your answers are completely anonymous. Please indicate whether you or a family member has ever experiened any of the following: (all are yes/no)
Y N

50. Diagnosis of Alzheimers disease 51. Diagnosis of dementia 52. Diagnosis of Parkisons disease 53. Had a stroke 54. Loss of a spouse (resulting from the previously mentioned diseases) 55. Loss of a family member (resulting from the previously mentioned diseases) 56. Loss of a friend (resulting from the previously mentioned diseases)

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Y

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N

Please indicate whether you or a close friend has ever experiened any of the following: (all are yes/no) 57. Diagnosis of Alzheimers disease 58. Diagnosis of dementia 59. Diagnosis of Parkisons disease 60. Had a stroke 61. Loss of a spouse (resulting from the previously mentioned diseases) 62. Loss of a family member (resulting from the previously mentioned diseases) 63. Loss of a friend (resulting from the previously mentioned diseases)

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PERCEPTIONS General Aging Expectations 64. As you age, which of the following areas changes? [Reference definition: G = Great change, A = Average change, S = Slight change, N = No change] G A S N Physical Mental Environmental (i.e. change in your home or home setting) Relationship Spirituality
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65. Which of the areas listed above changes the the most? (check only one)

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Physical

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Mental

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Environmental

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Relationship

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Spirituality

66. Which change is the most difficult adapt to? (check only one)
Physical Mental Environmental Relationship Spirituality

Tell us how much you agree with the following statements: [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A D 67. Aging is a gradual process. 68. There are some benefits of aging. 69. Aging happens overnight. (You wake up feeling old.) 70. I am afraid of aging. 71. Independence is something you strive for in older age. 72. Aging speeds up after a major health event. 73. There are more benefits to aging than negatives. 74. Losing independence is a natural part of aging. 75. Aging is a negative process. 76. I am comfortable with the idea of aging.

SD

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SD

General Aging Values [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A D

! ! 78. The aging population is viewed negatively. ! 79. The value of the elderly is associated with their appearance. 80. The value of the elderly is associated with their mental capacity. ! 81. The value of the elderly is associated with their physical abilities. ! 82. The value of the elderly is associated with their past experiences. ! ! 83. The value of the elderly is associated with their age. ! 84. People do not have respect for elders. ! 85. The aging population is viewed positively.
77. People generally have respect for elders.

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D

As I age, I am afraid of? [Reference definition: G = greatly fear, S = somewhat fear, N = neutral, D = do not fear] G S N 86. Isolation 87. Alzheimers Disease 88. Memory Loss 89. Mild Cognitive Impairment
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G 90. Poor physical health 91. Stroke 92. Loss of Independence 93. Parkinsons disease 94. Loss of family or friends 95. Dementia (non-specific)

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Cognitive Aging Values [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A D 96. Memory loss is a natural part of aging. 97. Memory loss can be prevented. 98. Memory loss is genetic. 99. Memory loss depends on your lifestyle (exercise, diet, etc.). 100. Memory loss cannot be prevented. 101. Memory loss can be treated. 102. Memory loss is not associated with aging.

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SD

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Memory loss is caused or influenced by [Reference definition: NI = Not at all important, NV = Not very important, I = Important, EI = Extremely Important] NI NV I 103. Social environmental factors (e.g. friends) 104. Traumatic experiences 105. Genetics / biology 106. Personality 107. Taking illegal drugs 108. Stress 109. Upbringing 110. Supernatural forces (e.g. hex) 111. Past sins or mistakes of my ancestors or past life 112. Alcohol ROLES

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EI

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113. Who do you expect to offer you support? [Reference definition: D = Do not expect at all, EL = Expect a little, E = Expect, G = Greatly Expect, NA = Not Applicable]
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D Spouse Children Other family (brothers, sisters, etc.) Friends Neighbors Coworkers Churchmembers 114. Do you live with any of these? [Reference dictionary: Y = Yes, N = No, NA = Not Applicable]

EL

NA

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Y

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N

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NA

Spouse Children Other family (brothers, sisters, etc.) Friends Neighbors

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SD

Place of Care: [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A D 115. Care for the elderly should be in the home. 116. Care for the elderly should be in a care facility. 117. It is safest to be cared for in a nursing home. 118. Care for the elderly should be the responsibility of professionals. 119. I prefer to live in my home. 120. It is safest to be cared for in the home. 121. I prefer to live in a community setting (independent living / assisted living / nursing home).

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Individual: Tell us how much you agree with the following statements: [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A D 122. Iam the sole person in charge of my health. 123. I will remain independent even in my older years. 124. I rely on others to maintain my health. 125. I do not want to burden anyone with my care as I grow older. 126. It is my right to be cared for in my older years.

SD

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Primary Caregiver: 127. Is your health such that you currently need a caregiver? 128. If you needed care, who would be your primary caregiver? (check only one)

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Friend

Yes

No

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Self

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Spouse

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Other family member

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Health care professional

129. Who would you want to be your primary caregiver? (check only one)
Self Spouse Other family member Friend Health care professional

Family [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A 130. It is the duty of a child to care for the well being of an aging parent 131. It is up to the children if they want to directly care of an aging parent. 132. It is the job of a professional to care for the well being of the elderly. 133. I expect a family member to attend my visits to the physician whenever needed. 134. I do not want to be a burden on my family as I grow older. 135. I expect to be alone when I visit my physician. 136. I look forward to having my family caring for me as I grow older. .

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SD

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Neighbors (community): [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A 137. I would trust a neighbor to take care of my parents while I am at work. 138. I have asked a neighbor to care for my parents while I am at work. 139. I have asked a neighbor to care for my parents while I am running errands.

SD

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RESOURCES Support in seeking help How helpful are or were the following in recommending or helping you to visit a health professional: [Reference definition: NH = NOT helpful, SH = Slightly helpful, H = Helpful, VH = Very helpful] NH SH H 140. Family and friends (not including clergy/religious leads or health professionals) 141. Health professional (i.e. physician/nurse) 142. Clergy or religious/spiritual leader 143. Church members 144. Neighbor or community health workers (i.e. promotores) 145. Support groups

VH

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Types and Sources of Care for Cognitive Health In the past, have you [Reference dictionary: Y = Yes, N = No, NA = Not Applicable] Y 146. Discussed your brain health with a profesional that is NOT a health provider? 147. Discussed your brain health with you family or friends? 148. Used a hot-line or a self-help group to discuss your brain health? 149. Discussed your brain health issues with a religious leader (e.g. Father, priest, minister, Pastor, reverend, bishop, Mauivi, etc.)? 150. Discussed your brain health issues with a church member (someone from your Religious community that is not a religious leader)? 151. Discussed your brain health issues with a folk / traditional healer? (e.g. Curandero, Sobador, Yerbero, Shaman, etc.) 152. Used home or traditional remedies for brain health issues (e.g. hot water bath, Teas, herbs, meditation, etc.)? 153. Used prescription medicine for brain health (including antidepressants)? 154. Used alcohol or illegal drugs to self medicate? 155. Had screening tests performed to assess your brain health? 156. Accessed the Internet to gain information about your brain health? Intent or likelihood ot using health services for cognitive health If you were to experience significant brain health problems, how likely is it that you would: [Reference definition: U = Unlikely, SU = Somewhat unlikely, SL = Somewhat Likely, L = Likely] U SU SL 157. Visit a brain health professional such as a neurologist, psychiatrist, family practitioner or other physician? 158. Discuss brain health issues with physicians, nurses or other human services professionals? 159. Discuss brain health issues with your family? 160. Discuss brain health issues with your friends? 161. Use a hot-line or self-help group to discuss brain health issues? 162. Keep it to yourself? 163. Discuss your brain health issues with a religious leader (e.g. Father, priest, minister, Pastor, reverend, bishop, Mauivi, etc.)? 164. Discuss your brain health issues with a folk / traditional healer? (e.g. Curandero, Sobador, Yerbero, Shaman, etc.) 165. Used home or traditional remedies for brain health issues (e.g. hot water bath, teas, herbs, meditation, etc.)? 166. Used prescription medicine for brain health? 167. Used alcohol or illegal drugs to self medicate?
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NA

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U 168.Had screening tests performed to assess your brain health?

SU

SL

Perception of Needs and Quality of Services Please indicate if you believe: [Reference definition: SA = Strongly agree, A = Agree, D = Disagree, SD = Strongly disagree] SA A 169. Most health professionals have respect for peoples culture and values. 170. There is a need for services to prevent brain health issues. 171. There is a need for screening services for brain health issues. 172. There is a need for services to educate elderly about brain health issues. 173. There is a need for service to educated middle-aged aduts about brain health issues. 174. There is a need for services to suuport family caregivers of elderly with brain health issues that may affect their parents. 175. There is difficulty scheduling health care appointments on a regular basis (e.g. cancellations, rescheduling, etc.) 176. There are frequent changes of the professional I am assigned to. 177. When seeking services, I am assigned someone who cannot speak or understand my primary language. 178. The facility/clinic provides written brain health information in my primary language. 179. The facility/clinic has staff who speak/understand my primary language.

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SD

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Barriers to use Which of the following have been reasons to NOT seeking help with brain health concerns? [Reference dictionary: Y = Yes, N = No, NA = Not Applicable] Y 180. Lack of transportation. 181. Lack of health insurance / could not afford to pay for the services. 182. I was afraid to seek services because of my immigration status or the status of family or friends. 183. The reputation of the service providers is not good. 184. I could not take time off from work. 185. I didnt know that what I was experiencing was abnormal. 186. Language and/or cultural barriers. 187. I did not know where to go. 188. I believe that the treatment would be ineffective. 189. I was embarrassed or did not want people to know. 190. My family would NOT approve or wouldnt see it as necessary.
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NA

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Y 191. The service hours are inconvenient. 192. Did not seek services due to discrimination at the clinic or facility. 193. A fear of knowing the truth.

NA

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TREATMENT How helpful do you believe each of the following factors are in the treatment of memory loss? [Reference definition: NH = Not helpful at all, SH = Somewhat helpful, H = Helpful, VH = Very Helpful] NH SH H VH 194. Medication 195. Counseling 196. Herbs 197. Talking with friends and family 198. Spiritual healing/cleansing 199. Therapy 200. Taking a vacation or holiday 201. Exercise and physical activity 202. Meditation or prayer SPIRITUALITY 203. How does spirituality change as we age?

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Greatly increases

Increases

Remains the same

Decreases

Greatly decreases

204. I belong to a faith community. 205. How often do you attend your faith community?

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Yes

No

Every day 1-3 times a week Holidays Rarely Never Afl [Reference definition: SA = Strongly agree, A = Agree, N = Neutral, D = Disagree, SD = Strongly disagree] SA A N D

206. My spiritual life results mainly on my one-on-one relationship with God. 207. My spiritual life rests mainly on my relationship with my faith community.

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SD

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YOUR PERSPECTIVE In my community, I believe that: [Reference definition: SA = Strongly agree, A = Agree, N = Neutral, D = Disagree, SD = Strongly disagree] SA A N D 208. Elderly are greatly respected and have an important place in society. 209. Aging is viewed as something to look forward to. 210. Aging parents should live with their relatives. 211. Parents and grandparents should be treated with great respect regardless of differences in views. 212. A person should often do activities with his or her immediate and extended family.
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SD

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LANGUAGE [Reference definition: E = Only English , EL = English and another lanuage, O = Only another language] E EL O 213. In general, what language(s) do you read and speak? 214. What language(s) do you mostly speak at home?

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E

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EL

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O

215. What language(s) do you usually speak with your friends? 216. What best describes your status in the United States?

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Work permit

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US citizen Non-immigrant status

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Permanent legal resident Undocumented

Prefer not to say

217. Survey completed in what language? 218. What is the worst thing about aging?

English

Spanish

219. What is the best thing about aging?

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