Age related changes can affect the lifestyle/quality of life of the elderly. What do you think are the two most prevalent ag

NSG4067 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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