Name    : 

Age     :
Gender  : Male        Female  



1. What is the average age of people who stay here?
50-60   60-70   70-80   Above 80

2. Do you earn a living?
Yes     No

3. How often do your relatives visit/call?
Often   Sometimes   Rarely   Never

4. How is the attitude of staff towards you?
Excellent   Good   Average   Bad

5. What is the quality of food you get>
Excellent   Good   Average   Bad

6. Is tha food provided according to your health needs?
Yes     No

7. Do you get ample amount of food?
Yes     No   Sometimes

8. What has led to the change in the attitude of young generation towards you?
Economic Syructure   Urbanisation   Modernisation   Erosion of social values

9. Do they provide you with proper sanitary in washroom?
Yes     No

10. Is the staff always available for you?
Yes     No

11. Do you get medicines on time?
Yes     No

12. How often do orgaisations/people visit you?
Often   Sometimes   Rarely

13. How often do you interact with the outside world?
Often   Sometimes   Rarely   Never

14. Do the management take care of your hobbies and interests?
Yes     No   Sometimes

15.Are the beds and other products comfortable?
Yes     No

16. In the scale of 1-10 rate the overall organization.