NSG 4067: GERONTOLOGICAL NURSING,
PATIENT QUESTIONNAIRE
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
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________
Page 1 of 4
© 2015 South University
PATIENT QUESTIONNAIRE
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
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________
Page 1 of 4
© 2015 South University
