Gerontological_NursingPatient_QuestionnaireINTERVIEW_OF_CHOSEN_ELDER

Gerontological Nursing

Patient Questionnaire

INTERVIEW OF CHOSEN ELDER ADULT

Name: ________________________________ Age: ________________

Brief Introduction (Background information):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

1. Philosophy on living a long life

2. Thoughts about when a person is considered “too old”

3. Opinion on the status and treatment of older adults

4. Beliefs about health and illness

5. Health promotion activities he or she participates in

6. Something special that helped the person live so long

7. Life span of other family members

8. Special dietary traditions in patient’s culture attributed with aiding long life

9. Any remedies/medications that have been handed down in family/group. If yes, describe. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. Patient’s description of current and past health status

11. The values that guided life so far

Additional Questions

1. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Summary

Contrast of client’s responses with findings in current literature

· ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Patient Questionnaire

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