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A Global Response to Elder Abuse - page 76 / 149

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A GLOBAL RESPONSE TO ELDER ABUSE AND NEGLECT

  • Has there ever been a day or longer when you did not have sufficient food?

Yes p No p

N/A p R/A p

  • Does the person ever refuse to take you shopping?

Yes p No p

N/A p R/A p

  • Are you ever made to feel like you are worthless or a burden?

Yes p No p

N/A p R/A p

If "Yes", Explain:

  • Are you ever reluctant or afraid to ask for things that you want or need?

Yes p No p

N/A p R/A p

If "Yes", Explain:

  • 22.

    Do you have any concerns either in:

  • 1.

    Feeling secure that help will always be available

  • 2.

    Quality of the care that you receive

  • 3.

    Feeling indebted to the person providing the care

  • 4.

    Other

Explain:

Yes p No p N/A p R/A p

Yes p No p N/A p R/A p

Yes p No p N/A p R/A p

Yes p No p N/A p R/A p

PAGE 61

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