EXPLORING THE PSYCHOSOCIAL PROBLEMS FACED BY THE
INSTITUTIONALIZED ELDERLY PERSONS
Questionnaire
Title: Exploring the Psychosocial Problems Faced by Institutionalized Elderly Persons
Section 1: Demographic Information
1. Name: ______________________
1. Age: _______________________
2. Gender: ☐ Male ☐ Female ☐ Other
3. Marital Status: ☐ Married ☐ Widowed ☐ Divorced ☐ Single
4. Education Level: ☐ No Formal Education ☐ Primary ☐ Secondary ☐ Higher
5. Duration of Stay in the Institution: ________ (in months/years)
6. Do you have any living family members? ☐ Yes ☐ No
7. How often do you receive visits from family/friends?
☐ Weekly ☐ Monthly ☐ Rarely ☐ Never
8. Religion: ________________
9. Place of birth: ☐Urban ☐Rural
10. Financial assistance:
11. Occupation (Previous): _________________
12. Life insurance: ☐Yes ☐No
13. Medical insurance: ☐Yes ☐No
14. Are you currently taking any medications? ☐ Yes ☐ No
15. Do you currently have any chronic illness? ☐ Yes ☐ No
Section 2: Geriatric Depression Scale (GDS-15)
(Please answer Yes/No for each question)
Statements Yes No
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and
interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you hopeful about the future?
6. Are you bothered by thoughts of helplessness?
7. Do you prefer staying at home rather than going out and
doing new things?
8. Do you feel you have more memory problems than
most?
9. Do you feel happy most of the time?
10. Do you often feel helpless?
11. Do you often feel restless and fidgety?
12. Do you frequently worry about the future?
13. Do you often feel downhearted and blue?
14. Do you feel pretty worthless the way you are now?
15. Do you ever feel that life is not worth living?
Section 3: PERCEIVED STRESS SCALE
(PERCEIVED STRESS SCALE by Sheldon Cohen)
(Please rate how much you agree with the following statements on a scale of 1 to 5.)
Statements Strongly Disagree Neutral Agree Strongly
Disagree (2) (3) (4) Agree (5)
(1)
1. In the last month, how often have
you been upset because of
something that happened
unexpectedly?
2. In the last month, how often have
you felt that you were unable to
control the important things in your
life?
3. In the last month, how often have
you felt nervous and “stressed”?
4. In the last month, how often have
you felt confident about your ability
to handle your personal problems?
5. In the last month, how often have
you felt that things were going your
way?
6. In the last month, how often have
you found that you could not cope
with all the things that you had to
do?
7. In the last month, how often have
you been able to control irritations
in your life?
8. In the last month, how often have
you felt that you were on top of
things?
9. In the last month, how often have
you been angered because of things
that were outside of your control?
10. In the last month, how often
have you felt difficulties were piling
up so high that you could not
overcome them?
