Gerontological NursingPatient 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 ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

1. Gerontological NursingPatient 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”
________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
______________________________________________

2. 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
________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_________________________________________

3. 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
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

4. __________________________________________
11. The values that guided life so far
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
Additional Questions
1.
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_______________________________
2.
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_______________________________
3.
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_______________________________

5. Summary
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
Contrast of client’s responses with findings in current literature
·
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
·
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
·
_____________________________________________________

6. _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
__________________________________________
Page 4 of 4
© 2015 South University