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Nutrition Survey

Thank you for taking part in this important survey for the Tennessee Commission on Aging and 

Disability. All answers will be kept confidential. 

Name: Today’s Date:

First Last

Gender: ☐ Male ☐ Female ☐ Other Age: County of Residence:

I. HOUSING AND FOOD

1. Do you live alone?

◯ Yes ◯ No

2. How many meals do you eat per day?

◯ 1 ◯ 2 ◯ 3 ◯ 4 ◯ Some days I do not eat any meals

3. Do you think the meals you eat are healthy?

◯ Yes ◯ No ◯ Unsure

II. TRANSPORTATION

1. Since the COVID-19 pandemic, how often have you...

Never Rarely Sometimes Often

Not able to leave the house when you 

wanted to because of a problem with 

transportation

◯ ◯ ◯ ◯

Felt lonely because you did not have 

the transportation you needed ◯ ◯ ◯ ◯

Not been able to get healthy food 

because of a problem with 

transportation

◯ ◯ ◯ ◯

Adapted from the Transportation Security Index
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2. How do you get to the senior center?

◯ Car ◯ Bus/Van ◯ Scooter

◯ Walk ◯ Other: 

3. How long would it take you to get to the nearest senior center?

◯ Less than 15 minutes ◯ 15-30 minutes

◯ 31-45 minutes ◯ More than 45 minutes

Meal Site Directory: https://www.tn.gov/content/tn/aging/our-programs/nutrition-services/congregate-mealsites.html

4. Do you have someone to ask for a ride if you need one?

◯ Yes ◯ No

5. Has an assistive device (i.e. cane, walker, wheelchair) limited you from going to the senior 

center?

◯ Yes ◯ No

6. Are you aware of the transportation services your county provides?

◯ Yes ◯ No

Statewide Transportation Map: https://www.tn.gov/content/tn/aging/resources/transportation-map.html

III. PHYSICAL, SOCIAL, PSYCHOLOGICAL HEALTH

1. How many minutes per day do you engage in physical activity?

◯ 0 ◯ 5-15 ◯ 15-30 ◯ 30-60 ◯ 60+

2. Please answer the following:

Yes No

I see or talk to my family members at least once a week ◯ ◯

I participate in social activities with family/friends or 

attend organized group activities at least once a week ◯ ◯

Within the past year I have suffered a major loss or 

change, like the death of a loved one or retirement ◯ ◯

Adapted from the Eldercare Locator Self-Assessment Checklist
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3. Please answer the following:

Never Rarely Sometimes Often

I lack companionship ◯ ◯ ◯ ◯

There is no one I can turn 

to ◯ ◯ ◯ ◯

I feel alone ◯ ◯ ◯ ◯

I have nothing in common 

with the people around 

me

◯ ◯ ◯ ◯

There is no one I feel 

close to ◯ ◯ ◯ ◯

I feel left out ◯ ◯ ◯ ◯

No one really knows me 

well ◯ ◯ ◯ ◯

I am unhappy being 

withdrawn ◯ ◯ ◯ ◯

Adapted from the UCLA Loneliness Scale

IV. TCAD NUTRITION PROGRAM

1. Since the COVID-19 pandemic, how satisfied are you with...

Very 

Satisfied Satisfied Unsatisfied Very Unsatisfied

The number of meals you 

receive per week ◯ ◯ ◯ ◯

The portion sizes of the 

food you receive ◯ ◯ ◯ ◯

The quality of the food 

you receive ◯ ◯ ◯ ◯
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2. BEFORE the COVID-19 pandemic, how often did you eat meals at the senior center?

◯ 1-2 times a week ◯ 3-4 times a week ◯ 5 times a week

3. AFTER the COVID-19 pandemic, how often have you eaten meals at the senior center? 

◯ 1-2 times a week ◯ 3-4 times a week ◯ 5 times a week

May we contact you if we have any further questions?

◯ Yes ◯ No

Any comments, suggestions, or questions?