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NSG4067 Gerontological Nursing
Patient Questionnaire
INTERVIEW OF CHOSEN ELDER ADULT
Name: ________________________________ Age: ________________
Brief Introduction (Background information):
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1. Philosophy on living a long life
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2. Thoughts about when a person is considered “too old”
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3. Opinion on the status and treatment of older adults
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4. Beliefs about health and illness
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5. Health promotion activities he or she participates in
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6. Something special that helped the person live so long
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7. Life span of other family members
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8. Special dietary traditions in patient’s culture attributed with aiding long life
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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
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11. The values that guided life so far
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Additional Questions
1. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Summary
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Contrast of client’s responses with findings in current literature
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