1. Where do you envision spending your future years?
 My current home
 Moving to a senior living community
 Moving to an apartment, condo or townhouse
 Not sure
 Other, please specify: ____________________
2. What are your 3 biggest concerns about your current lifestyle?
(Please rank order with 1 being the most important)
Health and wellness
Home maintenance
Staying active
Financial resources
Lack of companionship
Driving
Losing independence
Living at a distance from family
Other, please specify: ____________________
Please add comments below:
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3. Are you seriously considering a senior community as a place to live?
 Yes
 No
If yes, please write the community name and your impressions:
4. If yes, when would you anticipate making this move?
 Within the current year
 1-2 years
 3-5 years
 5+ years
5. What would prevent you from moving to a senior community? o Cost o Loss of independence o Connection to your home o General perceptions or impressions o Not sure what it offers (e.g. lifestyle, culture) o Other, please specify or comment below:
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6. What are some factors that would help you determine whether to move into a senior community?
7. Which of the following services are important to you in a senior community? (Please check all that apply) o Medication management o Home care coordination with 24 hr. pharmacy o On-site skilled nursing care o On-site podiatry, vision care and dental care o Staff working from a personalized care plan o Escorts to medical appointments o On-site wellness clinic o o o
Hospital discharge coordination
24 hr. emergency response system
Social work services o On-call RN or doctor o On-site physical therapy or other rehab services
8. Which of the following conveniences are important to you in a senior community? (Please check all that apply) o Hair salon/spa o On-site bank o Convenience store o Scheduled transportation
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o Fitness Center o Restaurant-style dining o Internet/Wi-Fi access o Concierge services
Other o Flexible meal options
9. What activities are important to you?
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Long Term Care
The following questions relate to meeting your long term care needs. Long term care can refer to a variety of situations. It can mean living in your home with help, relocating to an assisted living residence or entering a nursing home. Please keep this in mind as you think about these questions.
1. Do you have long-term care insurance?
 Yes
 No
2. How will you pay for your long term care needs? (Check all that apply)
 Private pay
 Public assistance
 Veterans benefits
 Family assistance
 A combination of the above
 Other, please specify below:
3. To what extent are you concerned about the following?
Very
Concerned
Somewhat
Concerned
Not at all
Concerned
Your access to long-term care in the future
The cost of long-term care in the future
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Location
As a place to live, how appealing are the following areas?
Ann Arbor
Not
Appealing
Unappealing Neither
Unappealing nor
Appealing
Appealing Very
Appealing
Chelsea
Dexter
Milan
Saline
Whitmore
Lake
Ypsilanti
Other
After completing this questionnaire, please take some time to think about how you have answered the questions and what this means about your future living arrangements.
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