Patient Questionnaire
INTERVIEW OF CHOSEN ELDER ADULT
Name: ________________________________ Age: ________________
Brief Introduction (Background information):
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- Philosophy on living a long life
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- Thoughts about when a person is considered “too old”
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- Opinion on the status and treatment of older adults
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- Beliefs about health and illness
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- Health promotion activities he or she participates in
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- Something special that helped the person live so long
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- Life span of other family members
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- Special dietary traditions in patient’s culture attributed with aiding long life
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- Any remedies/medications that have been handed down in family/group. If yes, describe. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Patient’s description of current and past health status
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- The values that guided life so far
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Additional Questions
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Summary
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Contrast of client’s responses with findings in current literature
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