Old Age Well-being Survey

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Name
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Date of birth
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Gender
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Occupation
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Have you started planning for retirement?
Yes

No
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Please elaborate

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Are you confident of a comfortable retirement ?
Yes

Unsure

No
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How comfortable are you with your savings?
Not at all

Slightly

Moderately

Very

Extremely
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Do you have any outstanding loans/payments? Check all that may apply.
Rent

Mortgage

Credit cards

Taxes
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How have you prepared for retirement? Check all that apply.
Pension programs

Savings account

401(K), 403 (B) or equivalent

Individual retirement account

Certificates of deposit

Mutual funds

Stocks

Bonds
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How often do you go for health checkups?
Never

Rarely

Annually

Monthly

Weekly
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Do you have any long-term illnesses?
Yes

No
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Please elaborate

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Do you have healthcare benefits?
Yes

No
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Please specify what type?
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Do you have insurance?
Yes

No
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Please specify what type?
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What are your biggest concerns about aging? Please elaborate below.

0 / 5000
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What could be done to improve your situation? Please elaborate below.

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