Preferences for Everyday Living Inventory

Preferences for Everyday Living Inventory

Excerpted for GH Activities Assessment

Elder’s Name: ______Date: ______

Bold - instructions to read to the elder

Italics - Instructions that are to serve as cues for you

Comments

1. / Do you like spending time with large groups of people? / not at all a little some alot no pref N/A / Comments
2 / Do you like spending time by yourself? / not at all a little some alot no pref N/A
3 / Do you like being a member of clubs, committees, and other organizations? / not at all a little some alot no pref N/A
[IF “NOT AT ALL” SKIP TO 4]
4. / Do you like to keep in regular contact with your family? / not at all a little some alot no pref N/A
[IF “NOT AT ALL” SKIP TO 5]
a. /

[Ask for one family member at a time: first name, relationship, mode(s) of contact, and frequency of contact.]

Tell me the name of one family member you keep in contact with.
What kind of contact do you have with him or her (e.g., phone, cards, visits, etc.)?
Adding all these ways you keep in touch, how often do you have contact with him or her? /

Comments

First Name / Relationship / Mode(s)
of contact / Total frequency of contact
Relationships: / Mode: / Frequency:
1 = spouse/partner / 1 = phone / 1 = daily
2 = child / 2 = cards/letters / 2 = 2-3 times/week
3 = sibling / 3 = 4-mail / 3 = weekly
4 = in-law / 4 = I visit them / 4 = 2-3 times/month
5 = grandchild / 5 = they visit me / 5 = monthly
6 = niece/nephew / 6 = live with / 6 = every few months
7 = other (specify) / 7 = other (specify) / 7 = on holidays
5. / Do you like touching someone you care about?
Do you like the following kinds of physical contact? / not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO 6]
a. shaking hands………………………………………………….. / no yes / no pref N/A
b. holding hands…………………………………………………. / no yes / no pref N/A
c. sitting close together………………………………………. / no yes / no pref N/A
d. hugging…………………………………………………………. / no yes / no pref N/A
e. kissing……………………………………………………………. / no yes / no pref N/A
f. getting a back rub……………………………………………. / no yes / no pref N/A
g. other: (specify)……………………………………………….. / no yes / no pref N/A
6. / Do you like meeting new people? / not at all a little some alot no pref N/A
7. / Do you like animals?
Do you like the following kinds of animals: / not at all a little some alot no pref N/A
[IF “NOT AT ALL” SKIP TO o]
a. dogs…………..………………………………………………….. / no yes / no pref N/A
b. cats…………….…………………………………………………. / no yes / no pref N/A
c. fish……………………….………………………………………. / no yes / no pref N/A
d. birds…..…………………………………………………………. / no yes / no pref N/A
e. other: (specify)……………………………………………….. / no yes / no pref N/A
Do you like the following kinds of contact with animals (imagine you had no health or apartment restrictions):
f. petting………………………………………………………….. / no yes / no pref N/A
g. holding in lap…………………………………………………. / no yes / no pref N/A
h. playing with…………………………………………………… / no yes / no pref N/A
i. feeding………………………………………………………….. / no yes / no pref N/A
j. walking………………………………………………………….. / no yes / no pref N/A
k. training…………………………………………………………. / no yes / no pref N/A
l. watching………………………………………………………… / no yes / no pref N/A
m. animal as guard………………………………………………. / no yes / no pref N/A
n. would you like to have a pet now?……………………… / no yes / no pref N/A
o. when was the last time you had a pet?………………… / N/A
p. What is/was your pet’s name? ______/ N/A
q. What kind of pet did you have?______/ N/A
r. Are you allergic to animals?….…………………………… / no yes / no pref N/A
If yes, what kind(s)?______/ no yes / no pref N/A
s. Are you afraid of animals?…………………………………. / no yes / no pref N/A
If yes, what kind(s)?______/ no yes / no pref N/A
1. / Do you like to be active? /

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #2]
a. Do you like to exercise in the…
1. morning………………………………………………… / no yes / no pref N/A
2. afternoon………………………………………………. / no yes / no pref N/A
3. evening…………………………………………………. / no yes / no pref N/A

Do you have an interest in, or think you would have an interest in the following kinds of activities?

b. / walking…………………………………………………………. / no yes / no pref N/A
c. / biking…………………………………………………………… / no yes / no pref N/A
d. / swimming……………………………………………………… / no yes / no pref N/A
e. / calisthenics/stretching…………………………………….. / no yes / no pref N/A
f. / yoga/tai chi……………………………………………………. / no yes / no pref N/A
g. / stair climbing…………………………………………………. / no yes / no pref N/A
h. / racquet sports………………………………………………… / no yes / no pref N/A
i. / bowling………………………………………………………… / no yes / no pref N/A
j. / weight lifting ……………………………………………….. / no yes / no pref N/A
k. / golf …………………………………………………………….. / no yes / no pref N/A
l. / other (specify)……………………………………………….. / no yes / no pref N/A
2. / Do you like to participate in religious/spiritual activities? /

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #3]
a. What is your religion? /

no pref N/A

Do you like to do the following religious/spiritual activities:

b. / attend religious services………………………………….. / no 1 / no pref N/A
c. / pray……………………………………………………………… / no 1 / no pref N/A
d. / read scriptures………………………………………………. / no yes / no pref N/A
e. / listen to radio services or audiotapes of services…. / no yes / no pref N/A
f. / watch services on TV………….……………………………. / no yes / no pref N/A
g. / observe food restrictions because of your religion. / no yes / no pref N/A
What kind of restrictions?
h. / have visits from clergy…………………………………….
Visits from whom? / no yes / no pref N/A
i. / Receive holy communion [Do not ask this question if respondent is Jewish or Muslim.]
no yes / no pref N/A
j. / Are there any other religious/spiritual activities you
enjoy? / no yes / no pref N/A
Describe:
3. /

Do you like doing volunteer work?

/

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #4]

What kind of volunteer work do you like doing?

4. / Do you like music? /

not at all 2 some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #5]
Do you like, or would you like, to listen to the following types of music:
a. / country………………………………………………………… / no yes / no pref N/A
b. / jazz……………………………………………………………… / no yes / no pref N/A
c. / blues……………………………………………………………. / no yes / no pref N/A
d. / religious (hymns, gospel, klezmer)…………………….. / no yes / no pref N/A
e. / classical………………………………………………………… / no yes / no pref N/A
f. / big band (Mitch Miller, Lawrence Welk)……………….. / no yes / no pref N/A
g. / show tunes…………………………………………………… / no yes / no pref N/A
h. / opera…………………………………………………………… / no yes / no pref N/A
i. / popular/contemporary (Top 4no)………………………… / no yes / no pref N/A
j. / rock…………………………………………………………….. / no yes / no pref N/A
k. / folk …………………………………………………………….. / no yes / no pref N/A
l. / other (specify)………………………………………………. / no yes / no pref N/A
m. / Do you have favorite musicians? / no yes / no pref N/A
If Yes, specify:
Do you like to listen to music in the…
n. / morning……………………………………………………….. / no yes / no pref N/A
o. / afternoon…………………………………………………….. / no yes / no pref N/A
p. / evening………………………………………………………… / no yes / no pref N/A
q. / late night……………………………………………………… / no yes / no pref N/A
r. / Do you like to play a musical instrument?…………… / no yes / no pref N/A
What instrument(s) ______/ no pref N/A
s. / Do you like to sing?………………………………………… / no yes / no pref N/A
t. / Do you like to dance?……………………………………… / no yes / no pref N/A
What kind of dancing?
5. / Do you like doing hobbies? /

______

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #6]
Do you have an interest in, or think you would have an interest in the following kinds of activities?
a. / sewing…………………………………………………………. / no yes / no pref N/A
b. / painting………………………………………………………... / no yes / no pref N/A
c. / woodworking………………………………………………... / no yes / no pref N/A
d. / building things…………………………………………….… / no yes / no pref N/A
e. / collecting things (e.g., coins, stamps, figurines)…….. / no yes / no pref N/A
f. / crocheting………………………………………………….… / no yes / no pref N/A
g. / knitting………………………………………………….…….. / no yes / no pref N/A
h. / metal working………………………………………….…….. / no yes / no pref N/A
i. / fixing things………………………………………….………. / no yes / no pref N/A
j. / drawing/sketching………………………………….………. / no yes / no pref N/A
k. / ceramics………………………………….……………………. / no yes / no pref N/A
l. / gardening………………………………….………………….. / no yes / no pref N/A
m. / cooking………………………………………………………… / no yes / no pref N/A
n. / baking………………………………….………………………. / no yes / no pref N/A
o. / fishing………………………………….………………………. / no yes / no pref N/A
p. / playing cards………………………………….………………. / no yes / no pref N/A
q. / board games………………………………….………………. / no yes / no pref N/A
r. / bingo………………………………….………………………… / no yes / no pref N/A
s. / computers………………………………….…………………. / no yes / no pref N/A
t. / cars………………………………….…………………………… / no yes / no pref N/A
u. / other (specify) ………………………………….……………. / no yes / no pref N/A
6. / Do you like watching TV? /

______

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #no pref]
Do you like to watch TV in the…
a. / morning……………………………………………………….. / no yes / no pref N/A
b. / afternoon…………………………………………………….. / no yes / no pref N/A
c. / evening………………………………………………………… / no yes / no pref N/A
d. / late night……………………………………………………… / no yes / no pref N/A
Do you enjoy…
e. / news programs…………………………………………….. / no yes / no pref N/A
f. / nature programs…………………………………………… / no yes / no pref N/A
g. / political programs (e.g., Meet the Press)……………. / no yes / no pref N/A
h. / documentaries…………………………………………….. / no yes / no pref N/A
i. / dramas……………………………………………………….. / no yes / no pref N/A
j. / mysteries…………………………………………………….. / no yes / no pref N/A
k. / game shows………………………………………………… / no yes / no pref N/A
l. / soap operas………………………………………………… / no yes / no pref N/A
m. / comedies……………………………………………………. / no yes / no pref N/A
n. / cartoons…………………………………………………….. / no yes / no pref N/A
o. / movies……………………………………………………….. / no yes / no pref N/A
p. / sports (favorite team______) / no yes / no pref N/A
q. / other (specify) ……………………………………………. / no yes / no pref N/A
r. / Do you have any favorite TV programs? / no yes / no pref N/A
Describe:

I

7. / Do you like going to movies? /

not at all a little some alot no pref N/A

8. / Do you like listening to the radio?
Do you like to listen to the radio in the… /

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #N/A]
a. / morning……………………………………………………….. / no yes / no pref N/A
b. / afternoon…………………………………………………….. / no yes / no pref N/A
c. / evening………………………………………………………… / no yes / no pref N/A
d. / late night……………………………………………………… / no yes / no pref N/A
On the radio, do you enjoy listening to…
e. / music…………………………………………………………… / no yes / no pref N/A
f. / sports broadcasts…………………………………………… / no yes / no pref N/A
g. / news……………………………………………………………. / no yes / no pref N/A
h. / talk shows…………………………………………………….. / no yes / no pref N/A
i. / religious programs…………………………………………. / no yes / no pref N/A
j. / other (specify)……………………………………………….. / no yes / no pref N/A
9. / Do you like reading?
Do you like to read in the… /

not at all 2 some alot no pref N/A

[IF “NOT AT ALL” SKIP TO o]
a. / morning……………………………………………………….. / no yes / no pref N/A
b. / afternoon…………………………………………………….. / no yes / no pref N/A
c. / evening………………………………………………………… / no yes / no pref N/A
d. / late night……………………………………………………… / no yes / no pref N/A
Do you like to read…
e. / fiction…………………………………………………………… / no yes / no pref N/A
f. / Science fiction…………………………………………… / no yes / no pref N/A
g. / magazines……………………………………………………………. / no yes / no pref N/A
h. / romances…………………………………………………….. / no yes / no pref N/A
i. / nonfiction…………………………………………. / no yes / no pref N/A
j. / biographies……………………………………………….. / no yes / no pref N/A
k. / Poetry / no yes / no pref N/A
l. / mysteries / no yes / no pref N/A
m. / newspaper / no yes / no pref N/A
n. / Other (specify) / no yes / no pref N/A
o. / Do you enjoy listening to books on tape? / no yes / no pref N/A
p. / Do you enjoy having someone read to you? / no yes / no pref N/A
10. / Do you like cultural activities such as concerts, theater, and museums? /

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO 11]
a. / Do you like attending musical concerts?…………….. / no yes / no pref N/A
b. / Do you like attending plays?…………………………….. / no yes / no pref N/A
c. / Do you like going to museums?………………………… / no yes
[IF “NOT AT ALL” SKIP TO h] / no pref N/A
Do you enjoy going to museums of…
d. / art………………………………………………………………….. / no yes / no pref N/A O10d
e. / science……………………………………………………………. / no yes / no pref N/A
f. / history……………………………………………………………. / no yes / no pref N/A
g. / oher (specify)………………………………………………….. / no yes / no pref N/A
h. / nonfiction…………………………………………. / no yes / no pref N/A
i. / biographies……………………………………………….. / no yes / no pref N/A
11 / Do you like to eat at restaurants?
Do you like to eat out for… /

not at all a little some alot no pref N/A

[IF “NOT AT ALL” SKIP TO #12]
a. / breakfast……………………………………………………….. / no yes / no pref N/A
b. / lunch……………………………………………………………. / no yes / no pref N/A
c. / dinner…………………………………………………………… / no yes / no pref N/A
d. / coffee or other beverages………………………………… / no yes / no pref N/A
Do you like the following kinds of food?
e. / Chinese…………………………………………………………. / no yes / no pref N/A
f. / Italian…………………………………………………………… / no yes / no pref N/A
g. / French…………………………………………………………. / no yes / no pref N/A
h. / Mexican………………………………………………………… / no yes / no pref N/A
i. / American………………………………………………………. / no yes / no pref N/A
j. / seafood………………………………………………………… / no yes / no pref N/A
k. / pizza……………………………………………………………... / no yes / no pref N/A
l. / vegetarian……………………………………………………… / no yes / no pref N/A
1. Do you consider yourself a vegetarian? / no yes / no pref N/A
m. / fast food……………………………………………………… / no yes / no pref N/A
n. / other (specify) …………………………………………….… / no yes / no pref N/A
12. / Do you like to travel? /

not at all a little some alot no pref N/A

a. / Do you like traveling to other cities?………………….. / no yes / no pref N/A
b. / Do you like traveling to other countries?…………….. / no yes / no pref N/A

Are there activities that you wish to do or learn that you have never done or tried before?

Is there anything else about your activity preferences that you would like to tell us?

1