Use this tool to create a custom PELI Detailed preference interview.

  1. Click or tap the questions below to include them in your custom interview.
  2. Click or tap the “Show The Custom Interview Questions” button at the bottom of this screen to display the full selected interview questions.
  3. Click or tap the “Save or Print This Custom Interview” button at the bottom of the screen to save as a PDF or print.
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Ask theSub Questions
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q01a. What name do you like me to use when I greet you?
  • ◯ First Name
  • ◯ Mr. / Mrs. / Ms. / Dr.
  • ◯ Nickname: ____________
  • ◯ Other___________
Q01b. What pronoun would you like me to use when I greet you?
  • ◯ He, His, Him
  • ◯ She, Her, Hers
  • ◯ They, Them, Theirs
  • ◯ Other___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Ask theSub Questions
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q02a. What time do you usually like to get up in the morning?
Before 7am
  • ◯ Earlier than 5am
  • ◯ Between 5-6am
  • ◯ Between 6-7am
After 7am
  • ◯ 7-8am
  • ◯ 8-9am
  • ◯ Whenever I wake up
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q03a.What is part of your morning routine?
  • ◯ Relax in bed
  • ◯ Drink coffee/tea
  • ◯ Read newspaper
  • ◯ Watch or listen to TV
  • ◯ Listen to radio/music
  • ◯ Get dressed
  • ◯ Brush teeth
  • ◯ Bathe/wash-up
  • ◯ Take medication
  • ◯ Smoke cigarette
  • ◯ Other____________
Q03a1. Comments on order of morning routine?
Q03b. Do you like to stay in bed before rising?
  • ◯ Yes
  • ◯ No
Q03c. If yes, how long do you like to stay in bed before getting up?
Under 30 min
  • ◯ Get up right away
  • ◯ Less than 15 mins
  • ◯ 15-30 mins
Over 30 min
  • ◯ 31-45 mins
  • ◯ Over 45 mins
  • ◯ Depends on:__________
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q04a. How often do you like to bathe?
  • ◯ Daily
  • ◯ Every other day
  • ◯ Twice a week
  • ◯ Once a week
  • ◯ Other_______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q05a. What time of day do you like to bathe?
  • ◯ Morning
  • ◯ Afternoon
  • ◯ Evening
  • ◯ Night
  • ◯ Whenever I want
  • ◯ Other____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q06a. What type of bathing do you prefer?
Type of Bath
  • Tub bath
  • Sponge bath
  • Bed bath
Type of Shower
  • Shower
  • Standing
  • Sitting
Other
  • Depends on:_____________
  • Other______________
Q06b. Do you like to decide how long you spend bathing?
  • ◯ Yes
  • ◯ No
Q06b1. If yes, how much time do you like to spend bathing?
20 mins or less
  • ◯ < 10 mins
  • ◯ 10-15 mins
  • ◯ 16-20 mins
21 mins or more
  • ◯ 21-30 mins
  • ◯ > 30 mins
  • ◯ Other______________
Q06c. Do you like a certain level of lighting when you bathe?
  • ◯ Yes
  • ◯ No
Q06c1. If yes, how bright do you like the lights?
  • ◯ Normal
  • ◯ Bright
  • ◯ Other______________
Q06d. Do you like a certain room temperature when you bathe?
  • ◯ Yes
  • ◯ No
Q06d1. If yes, which room temperature do you like?
Temperature
  • ◯ Cool (60-65° F)
  • ◯ Warm / Normal (65-75° F)
  • ◯ Hot (> 75° F)
Other
  • ◯ Other______________
Q06e. Do you like to listen to something when you bathe?
  • ◯ Yes
  • ◯ No
Q06e1. If yes, which do you like to listen to when you bathe?
Type of Sounds
  • ◯ Music
  • ◯ Nature
  • ◯ Water
Other
  • ◯ Nothing
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q07a. What do you usually like to wear for the day?
Q07b. What jewelry do you like to wear?
Q07c. Do you like to a carry a:
  • ◯ Bag
  • ◯ Watch
  • ◯ Wallet
Q07d. Do you like your clothes arranged a certain way?
  • ◯ Yes
  • ◯ No
Q07e. If yes, how do you like your clothes arranged?
Q07f. What do you like to wear to sleep?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q08a. What do you like to do to care for your mouth?
Teeth Care
  • ◯ Brush teeth
  • ◯ Brush tongue
  • ◯ Floss
Denture Care
  • ◯ Clean/soak dentures
  • ◯ How often?___________
  • ◯ Other___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q09a. How often do you like to care for your nails/have your nails cared for?
  • ◯ Daily
  • ◯ Weekly
  • ◯ Every other week
  • ◯ Monthly
Q09b. What do you like to do to care for your nails/have your nails cared for?
  • ◯ Cut/clip nails
  • ◯ Cut/clip cuticles
  • ◯ File nails with emery board
  • ◯ Clean under nails
  • ◯ File nails with nail file
  • ◯ Use nail finish/treatments
  • Type/brand: ______________
  • ◯ Polish nails
  • Type/brand/color:______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q10a. How do you like to care for your hair?
Daily Hair Needs
  • ◯ Comb/brushing
  • ◯ Hair styled
Styling Products
  • ◯ Type_________
  • ◯ Brand________
Beautician Services
  • ◯ Hair cut
  • ◯ Hair coloring
  • ◯ Plucking brows/face
Grooming
  • ◯ Shaving
  • ◯ Beard care
Other
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
  • ◯ Morning
  • ◯ Afternoon
  • ◯ Evening/night
  • ◯ Whenever I want
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q12a. How do you like to set up your room?
  • ◯ Nightstand / bed table
  • ◯ Bed / dresser
  • ◯ Chairs
  • ◯ Walker / wheelchair
  • ◯ Contents of closet
Q12a1. Comments on how you like furniture and other items arranged in your room:
Q12b. Do you like to display/decorate things in your room?
  • ◯ Yes
  • ◯ No
Q12b1. If yes, what things do you like to decorate your room with?
  • ◯ Personal keepsakes
  • ◯ Photos
  • ◯ Holiday decorations
  • ◯ Pictures / art
  • ◯ Decor
  • ◯ Curtains
  • ◯ Other__________
Q12c. Do you like to keep certain things near your bed?
  • ◯ Yes
  • ◯ No
Q12d. Which items do you like to keep by your bed?
  • ◯ Clock
  • ◯ Telephone
  • ◯ Tissues
  • ◯ Water
  • ◯ Eye glasses
  • ◯ Lamp / Light
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q13a. What personal belongings do you prefer to take care of yourself?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q14a. At what temperature do you like to keep your room?
  • ◯ Average (69-72°F)
  • ◯ On the warm side (>72°F)
  • ◯ On the cool side (<69°F)
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q15a. What lighting level do you prefer during the day?
  • ◯ Dim
  • ◯ Moderate
  • ◯ Bright
Q15b. Do you like to be able to adjust the shades during the day?
  • ◯ Yes
  • ◯ No
Q15b1. If yes, do you like to keep the shades:
  • ◯ Opened
  • ◯ Closed
  • ◯ It depends________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q16a. What time do you like to go to bed?
  • ◯ Earlier than 7 pm
  • ◯ 7-9 pm
  • ◯ 9-11 pm
  • ◯ After 11 pm
Q16b. How many hours of sleep do you like at night?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q17a. Tell me about your bedtime routine:
Q17b. What activities do you like to do as part of your bedtime routine?
  • ◯ Have a snack
  • ◯ Put on pajamas
  • ◯ Pick out clothes for next day
  • ◯ Brush teeth
  • ◯ Wash up
  • ◯ Listen to music
  • ◯ Watch or listen to TV
  • ◯ Read
  • ◯ Pray
  • ◯ Other: _______
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q18a. How do you like to set up your bed for comfort?
Q18b. Which things are important to you in setting up your bed for comfort?
Pillows
  • ◯ # of pillows_____
  • ◯ Position / fluff pillows
Blankets
  • ◯ # of blankets_____
  • ◯ Loosen blankets
  • ◯ Tuck blankets
Room
  • ◯ Adjust bed height / settings
  • ◯ Change the room temperature
  • ◯ Nightlight on
Doors
  • ◯ Open bedroom door
  • ◯ Shut bedroom door
Windows
  • ◯ Open windows
  • ◯ Close curtains
Other:
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q19a. What professionals do you like to see for medical care?
  • ◯ Physician
  • ◯ Nurse practitioner
  • ◯ Physician's assistant
  • ◯ Chiropractor
  • ◯ Acupuncturist
  • ◯ Massage therapist
  • ◯ Hypnotherapist
  • ◯ Faith healer
  • ◯ Other_________
Q19b. Do you like to continue to see your regular medical care professional?
  • ◯ Yes
  • ◯ No
Q19c. If yes, list medical care professional name and speciality:
  • Professional name:
  • Professional specialty:
  • Professional name:
  • Professional specialty:
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q20a. Which gender caregiver do you like for personal care (e.g., showering, dressing, toileting)?
  • ◯ Female
  • ◯ Male
  • ◯ No Preference
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q21a. What do you like your daily caregiver to know about your needs when going to the bathroom?
Q21b. Which bathroom needs do you like your daily caregiver to know about?
  • ◯ How often to go the bathroom
  • ◯ Which bathroom you prefer to use
  • ◯ Type of cleansing
  • ◯ Type of assistance needed
  • ◯ Use of stool softeners, suppositories, laxatives
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q22a. What kind of alcohol do you like to drink on occasion?
  • ◯ Wine
  • ◯ Beer
  • ◯ Hard liquor
  • ◯ Mixed drinks
  • ◯ Other_________
Q22b. On what occasions do you like to drink alcohol?
  • ◯ Special occasions
  • ◯ Holidays
  • ◯ Parties
  • ◯ Dinner
  • ◯ Bedtime
  • ◯ Other________
Notes:
  • ◯ No If no, skip to Q24
  • ◯ Yes If yes, continue to Q23B
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q23b1. Which tobacco products do you use?
  • ◯ Cigarettes
  • ◯ Cigars
  • ◯ Pipe
  • ◯ Chewing tobacco
  • ◯ Other________
Q23b2. Where do you like to use tobacco products?
Q23b3. When do you like to use tobacco products?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q24a. What family do you enjoy regular contact with?
  • Name/Relationship:
  • How Often:
  • Name/Relationship:
  • How Often:
  • Name/Relationship:
  • How Often:
Q24b. Are there family with whom you prefer not to have contact?
  • ◯ Yes
  • ◯ No
  • Name/Relationship:
  • Name/Relationship:
Q24c. Which ways do you like to keep in regular contact with family?
  • ◯ Visits in person
  • ◯ Talking on the phone
  • ◯ Email
  • ◯ Sending and getting cards/letters
  • ◯ Being intimate with your spouse or other
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q25a. What friends do you enjoy having regular contact with?
Friend #1
  • Name/Relationship:
  • How Often:
Friend #2
  • Name/Relationship:
  • How Often:
Q25b. Which ways do you like to keep in regular contact with them?
  • ◯ Visits in person
  • ◯ Talking on the phone
  • ◯ Email
  • ◯ Sending and getting cards/letters
  • ◯ Other_______
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q26a. Once every 3 months there is a meeting of staff to help plan your care. Do you like to attend the meeting?
  • ◯ Yes
  • ◯ No
Q26b. Which people do you like involved in discussions about your care?
Family/Friends
  • ◯ Spouse
  • ◯ Significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
  • ◯ Friends
Professional
  • ◯ Nurse
  • ◯ Doctor
  • ◯ Social worker
  • ◯ Daily caregiver
  • ◯ Other__________
Q26c. Which areas of your care do you like to discuss?
  • ◯ Care plan / treatment plan
  • ◯ Activities you are involved in
  • ◯ General health
  • ◯ Test results
  • ◯ Caregiving needs
  • ◯ Medication changes
  • ◯ Info about your routine
  • ◯ Info about your medical condition
  • ◯ Other_________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q27a. Which things help you feel better when you are upset?
Comfort
  • ◯ Eat something
  • ◯ Coffee
  • ◯ Smoke
Coping
  • ◯ Focus on how to solve the problem
  • ◯ Think about happier times
  • ◯ Not thinking about what upset you
Diversion
  • ◯ Dance
  • ◯ Listen to music
  • ◯ Read a book
  • ◯ Reading a card/letter
  • ◯ Watch or listen to comedy
  • ◯ Watch or listen to TV
  • ◯ Watering flowers
Exercise
  • ◯ Exercise
  • ◯ Sports
  • ◯ Take a walk
Relaxation
  • ◯ Be by yourself
  • ◯ Cry
  • ◯ Walk away
  • ◯ Pray/meditate
  • ◯ Relax
  • ◯ Take deep breaths
  • ◯ Other_________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q28a. Which professionals do you prefer talking to when you are sad or worried?
  • ◯ Nurse
  • ◯ Religious counselor
  • ◯ Daily caregiver
  • ◯ Social worker
  • ◯ Counselor/therapist
  • ◯ Psychologist
  • ◯ Psychiatrist
  • ◯ Physician/MD
  • ◯ Other_________
Q28b. Do you prefer medication rather than talking to a professional when you are upset?
  • ◯ Yes
  • ◯ No
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q29a. Which ways do you like staff to show they care about you?
  • ◯ Shaking your hand
  • ◯ Holding your hand
  • ◯ Giving a hug
  • ◯ Saying something nice
  • ◯ Joking with you
  • ◯ Smiling
  • ◯ Visiting, talking with you
  • ◯ Asking about how you are doing
  • ◯ Using a nice tone of voice
  • ◯ Patting you on the shoulder
  • ◯ Taking care of what you need
  • ◯ Getting a back or hand massage
  • ◯ Answering call bell in a timely manner
  • ◯ Other____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q30a. In which ways do you like staff to show you respect?
  • ◯ Greeting you, saying hello
  • ◯ Calling you Mr/Ms/Mrs/Miss/Dr
  • ◯ Calling you by commissioned rank
  • ◯ Knocking before entering your room
  • ◯ Helping you, asking what you need
  • ◯ Responding quickly to requests
  • ◯ Not talking down to you
  • ◯ Honoring your feelings
  • ◯ Thanking you
  • ◯ Listening to you
  • ◯ Being pleasant
  • ◯ Other___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q31a. Where do you like to use the phone in private?
  • ◯ Bedroom
  • ◯ Secured space with the door shut
  • ◯ Other___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q32a. Which of these activities do you like to keep private?
  • ◯ Using the toilet, urinal / bedpan
  • ◯ Getting dressed / changing clothes
  • ◯ Attending to my medical needs
  • ◯ Other ___________
Q32b. Which information do you like to keep private?
  • ◯ Your family
  • ◯ Your medical condition/care
  • ◯ Your finances
  • ◯ Other ___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q33a. What things do you like to keep locked up?
  • ◯ Jewelry
  • ◯ Money
  • ◯ Electronics
  • ◯ Other ___________
Q33b. Which places do you like to lock things to keep them safe?
  • ◯ A locked drawer
  • ◯ Locked closet/armoire
  • ◯ A safe
  • ◯ A safety deposit box
  • ◯ Other ___________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q34a. Which of the following is important to you when choosing a roommate?
Demographics
  • ◯ Age
  • ◯ How long they have lived here
Environment
  • ◯ Keeps area clean
  • ◯ Keeps lighting level low
  • ◯ Quiet/keeps noise level low
Functional Ability
  • ◯ Level of disability
  • ◯ Hearing ability
Olfactory
  • ◯ Does not wear perfume
  • ◯ Hygiene (body odors, gas, etc.)
  • ◯ Not a smoker
Personality traits
  • ◯ Quiet
  • ◯ Active
  • ◯ Polite
  • ◯ Social
TV habits
  • ◯ Amount
  • ◯ Time
  • ◯ Volume
Other
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q35a. What are your favorite foods for:
  • Breakfast:
  • Lunch:
  • Supper:
  • Favorite drinks:
  • Condiments:
  • Foods I dislike:
Q35b. Do you have certain ethnic or cultural food preferences?
  • ◯ Yes
  • ◯ No
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q36a. When do you prefer to eat:
  • ◯ Breakfast:_________
  • ◯ Lunch:_________
  • ◯ Dinner:_________
  • ◯ Whenever I am hungry
Q36b. How much time do you usually like to spend eating a meal?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q37a. Where do you like to eat while you are here/in a nursing home?
  • ◯ In your room
  • ◯ In the dining room
  • ◯In the bistro/café
  • ◯ In the cafeteria
  • ◯ At restaurants
  • (How often: ___________)
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q38a. Which of the following foods do you like to snack on?
Healthy
  • ◯ Fruits
  • ◯ Vegetables
Salty
  • ◯ Chips
  • ◯ Pretzels
  • ◯ Crackers
Sweets
  • ◯ Candy
  • ◯ Chocolate
  • ◯ Ice cream
Other
  • ◯ Beverages
  • ◯ Other______________
Q38b. When you you like to snack?
  • ◯ Morning
  • ◯ Afternoon
  • ◯ Evening/night
  • ◯ Whenever I want
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q39a. Which kind of restaurants do you like?
Type
  • ◯ Upscale
  • ◯ Fast food
  • ◯ Diner
Specialty
  • ◯ Italian
  • ◯ Pizza
  • ◯ Japanese
  • ◯ Hoagie/sub/sandwich
  • ◯ Other________
Q39b. Write name of favorite restaurant:
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q40a. Which kind of take-out food do you like to order?
Fast food
  • ◯ BBQ chicken
  • ◯ Hamburgers
  • ◯ Fish fry
  • ◯ Pizza
  • ◯ Wings
Specialty
  • ◯ Chinese
  • ◯ Italian
  • ◯ Japanese
Other
  • ◯Other________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q41a. In which ways do you like to spend time by yourself?
Contemplating
  • ◯ Looking out the window
  • ◯ Thinking
Leisure
  • ◯ Crossword puzzle / games
  • ◯ Listening to music
  • ◯ Reading
  • ◯ Watching a movie
Resting
  • ◯ Lying down
  • ◯ Napping
Spiritual
  • ◯ Meditating
  • ◯ Praying
Other
  • ◯ Other_________
Q41b. Where do you like to spend time by yourself?
  • ◯ Bedroom
  • ◯ Outside
  • ◯ Other________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q42a. Which people do you like to spend one-on-one time with?
Family
  • ◯ Spouse
  • ◯ Significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
Friends
  • ◯ Friends
  • ◯ Roommate
  • ◯ Other residents
Other
  • ◯ Staff
  • ◯ Other______________
Q42b. What do you like to do with someone one-on-one?
  • ◯ Catching up
  • ◯ Discussing care
  • ◯ Discussing facility
  • ◯ Playing games
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q43a. What do you like to do with groups of people?
Q43b. Which type of person do you enjoy in a group?
  • ◯ Friends
  • ◯ Other residents
  • ◯ Roommate
  • ◯ Family members
  • ◯ Other______________
Q43c. How many people do you like when doing things in a group?
  • ◯ Small group
  • ◯ Medium group
  • ◯ Large group
  • ◯ Very large group / crowd
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q44a. In which ways do you like to meet new people?
  • ◯ Social event
  • ◯ Discussion group
  • ◯ Enjoyable activity
  • ◯ Over coffee
  • ◯ Through another resident
  • ◯ Through staff
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q45a. Which kind of club(s) did you enjoy in the past?
Hobbies
  • ◯ Book club
  • ◯ Card club
  • ◯ Computer club
  • ◯ Crochet / knitting club
  • ◯ Glee club
  • ◯ Outdoors club
Political
  • ◯ Political club
Religious
  • ◯ Religious club
  • ◯ Church club
Social
  • ◯ Elks
  • ◯ Red Hat Society
Veterans
  • ◯ American Legion
  • ◯ VFW
Other
  • ◯ Other______________
Q45b. What kind of clubs do you enjoy now?
Hobbies
  • ◯ Book club
  • ◯ Card club
  • ◯ Computer club
  • ◯ Crochet / knitting club
  • ◯ Glee club
  • ◯ Outdoors club
Political
  • ◯ Political club
Religious
  • ◯ Religious club
  • ◯ Church club
Social
  • ◯ Elks
  • ◯ Red Hat Society
Veterans
  • ◯ American Legion
  • ◯ VFW
Other
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q46a. Which children do you enjoy being around?
  • ◯ Grandchildren
  • ◯ Great grandchildren
  • ◯ School groups
  • ◯ Other residents' visitors
  • ◯ Other_______________
Q46b. What activities involving children do you enjoy?
  • ◯ Watching them play
  • ◯ Playing with them
  • ◯ Listening to them
  • ◯ Talking with them
  • ◯ Teaching them
  • ◯ Other_______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q47a. Have you volunteered your time in the past?
  • ◯ Yes
  • ◯ No
Q47b. If yes, which ways have you volunteered your time in the past?
Children/Youth
  • ◯ Reading with / teaching children
  • ◯ School volunteer activities
Financial
  • ◯ Fundraising
  • ◯ Help with giving money or gifts to the sick and needy
Helping Others
  • ◯ Church volunteer activities
  • ◯ Shopping for other people
  • ◯ Make things for the sick or needy
Training
  • ◯ Helping people learn the computer
  • ◯ Coaching a sports team
Other
  • ◯ Other________________
Q47c. How do you like to volunteer your time now?
Children/Youth
  • ◯ Reading with / teaching children
Financial
  • ◯ Fundraising
Helping Others
  • ◯ Helping around the nursing home
  • ◯ Shopping for other residents
  • ◯ Helping the sick or needy
Training
  • ◯ Helping people learn the computer
  • ◯ Coaching a sports team
Other
  • ◯ Other________________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q48a. What is your religious background?
Q48b. Do you belong to a religious organization?
  • ◯ Yes
  • ◯ No
Q48c. If yes, which organization do you belong to?
  • ◯ Synagogue
  • ◯ Church
  • ◯ Mosque
  • ◯ Other______________
Q48d. If so, what is the name?
Q48e. Which religious services or practices do you like?
Dietary
  • ◯ Observe dietary requirements
  • ◯ Kosher foods
  • ◯ No meat on Fridays
Religious Practices
  • ◯ Read / study the Torah / Bible / Koran / Other
  • ◯ Pray / meditate
  • ◯ Visits from clergy, pastor, priest, rabbi
  • ◯ Observe holy days (Specify:______________)
  • ◯ (If Christian) Receive sacraments (Which ones?_____________)
Religious Services
  • ◯ Attend religious services
  • ◯ Listen to services on a tape / radio
  • ◯ Watch service on TV
Other
  • ◯ Other________________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q49a. In which cultural traditions do you like to participate?
Cultural
  • ◯ Eating traditional food
  • ◯ Wearing traditional dress
Celebrations
  • ◯ Celebrations
  • ◯ Festivals
  • ◯ Holidays
Military
  • ◯ Military traditions
Religious
  • ◯ Religious traditions
Other
  • ◯ Other______________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q50a. Which topics do you like to reminisce about?
Entertainment
  • ◯ Old radio shows
  • ◯ Old TV shows
  • ◯ Entertainers from the past
Interests
  • ◯ Fashions
  • ◯ Hobbies
  • ◯ Music
Life Experiences
  • ◯ Travel
  • ◯ Work
  • ◯ School
  • ◯ Where you came from
Relationships
  • ◯ Family
  • ◯ Friends
  • ◯ Pets
Sports
  • ◯ Sports teams_________________
  • ◯ Sports you participated in
Other
  • ◯ Other_____________
Q50b. With which people do you like to reminisce?
Family
  • ◯ Spouse
  • ◯ Significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
Friends
  • ◯ Friends___________
  • ◯ Other residents
Other
  • ◯ Staff
  • ◯ Other_____________
Q50c. Do you like to reminisce with a group of people?
  • ◯ Yes
  • ◯ No
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q51a. To which people do you like to give gifts?
Family
  • ◯ Spouse
  • ◯ Significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
Friends
  • ◯ Friends__________
  • ◯ Other residents
  • ◯ Other_____________
Q51b. Which kind of gifts do you like to give?
  • ◯ Money
  • ◯ Personal gifts
  • ◯ Gratitude
  • ◯ Flowers
  • ◯ Other_____________
Q51c. Is it important to you to give gifts on holidays or special occasions?
  • ◯ Yes
  • ◯ No
Q51d. If yes, on which holidays or special occasions do you enjoy giving gifts?
Celebrations
  • ◯ Father's Day
  • ◯ Mother's Day
  • ◯ Birthdays
Holidays
  • ◯ Halloween
  • ◯ Hanukkah
  • ◯ Christmas
  • ◯ Easter
  • ◯ Valentine's Day
Special Occasions
  • ◯ Anniversaries
  • ◯ Graduations
  • ◯ Weddings
Other
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q52a. At which stores do you like to shop?
  • ◯ Clothing store
  • ◯ Department store
  • ◯ Discount store
  • ◯ Dollar store
  • ◯ Grocery store
  • ◯ Hardware store
  • ◯ Mall
  • ◯ General store
  • ◯ Other___________
Q52b. Write names of favorite stores, if given.
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q53a. Which kinds of things do you like to do away from here?
Visits
  • ◯ Visit family
  • ◯ Visit friends
  • ◯ Visit old neighbors
Shopping/Dining
  • ◯ Go shopping
  • ◯ Go to the store
  • ◯ Go to a restaurant
Entertainment
  • ◯ Go to a movie
  • ◯ Go to a concert
  • ◯ Go to the theater
Outings
  • ◯ Go to a sporting event
  • ◯ Sightsee
  • ◯ Go for a ride
Other
  • ◯ Other______________
Q53b. How long do you like to spend away from here?
  • ◯ For an hour of two
  • ◯ For a day
  • ◯ Overnight
  • ◯ Other____________
Q53c. Whom do you like to be with if you are away from here?
Family/Friends
  • ◯ Family __________________
  • ◯ Friends _________________
  • ◯ Residents ______________
Staff
  • ◯ Recreation therapist
  • ◯ Nurse
  • ◯ Other ____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q54a. Which entertainment events did you enjoy in the past?
Entertainment
  • ◯ Concerts_________
  • ◯ Dance performances
  • ◯ Drama stage plays
  • ◯Movies
  • ◯ Musicals / musical plays / Operas
  • ◯ Ethnic music ______________
Outings
  • ◯ Parades
  • ◯ Museums_____________
  • ◯ Sporting event___________
Other
  • ◯ Casinos
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q55a. In which type of weather do you like to go outside?
Type of Day
  • ◯ Sunny
  • ◯ Cloudy / Overcast
  • ◯ Rainy
  • ◯ Snowy
Temperature
  • ◯ Hot
  • ◯ Warm
  • ◯ Cool
  • ◯ Cold
  • ◯ Other_____________
Q55b. Which things do you like to do outside when the weather is good?
Active Activities
  • ◯ Garden
  • ◯ Play
  • ◯ Walk
  • ◯ Work / outdoor tasks
Relaxation
  • ◯ Eat / drink
  • ◯ Nap
  • ◯ Sit
  • ◯ Smoke
  • ◯ Talk / visit
  • ◯ Tanning
  • ◯ Watch the birds / wildlife
  • ◯ Other_____________
Q55c. How many times do you like to go outside in a week?
  • ◯ Daily
  • ◯ 2-3 times a week
  • ◯ 4-5 times a week
  • ◯ Once a week
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q56a. Which tasks do you like to do to care for the place you live?
Home Maintenance
  • ◯ Decorating
  • ◯ Fixing things
  • ◯ Handling finances (balance checkbook, pay bills)
Housekeeping
  • ◯ Dishwashing
  • ◯ Dusting
  • ◯ Sweeping, vacuuming
Laundry
  • ◯ Folding laundry
  • ◯ Ironing
Organizing
  • ◯ Making bed
  • ◯ Organizing things (closets or drawers)
  • ◯ Picking up
Other
  • ◯ Tending plants
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q57a. Which outdoor tasks do you like to do to care for the place where you live?
Home Maintenance
  • ◯ Fixing things
  • ◯ Painting the house / fence
Yard Work
  • ◯ Cutting lawn
  • ◯ Planting flowers / vegetables
  • ◯ Shoveling snow
  • ◯ Sweeping
  • ◯ Trimming trees
  • ◯ Weeding
Other
  • ◯ Other____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q58a. Which kind of animals do you like to be around?
  • ◯ Birds
  • ◯ Cats
  • ◯ Dogs
  • ◯ Fish
  • ◯ Hamster / guinea pigs
  • ◯ Horses
  • ◯ Reptiles
  • ◯ Other___________
Q58b. Which type of contact do you enjoy with animals?
  • ◯ Feeding
  • ◯ Holding in your lap
  • ◯ Petting
  • ◯ Playing with
  • ◯ Riding
  • ◯ Watching
  • ◯Other___________
Q58c. Are you allergic to animals?
  • ◯ Yes
  • ◯ No
Q58d. If yes, what kind?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q59a. Which ways do you like to keep up with the news?
Conversation
  • ◯ Discussions with another person
  • ◯ Group discussions
Electronic Devices
  • ◯ Listen to the radio
  • ◯ Use the computer
  • ◯ Watch or listen to TV
Reading
  • ◯ Read magazines
  • ◯ Read newspaper
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q60a. Which topics do you like to learn more about?
Health
  • ◯ Eye problems
  • ◯ Hearing problems
  • ◯ Medical conditions: _______________
Leisure
  • ◯ Sports
Science/Religion
  • ◯ Science
  • ◯ Technology
  • ◯ Religion
World
  • ◯ History
  • ◯ News / current events
  • ◯ Places to travel
Other
  • ◯ Other__________
Q60b. Which ways do you like to learn about topics that interest you?
Group learning
  • ◯ Attend a talk
  • ◯ Discussion group
Self learning
  • ◯ Computer
  • ◯ Read
  • ◯ Talk with professional
  • ◯ Video
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q61a. Do you have difficulties reading due to eyesight?
  • ◯ Yes (Go to Q61b)
  • ◯ No (Skip to Q61c)
Q61b. Which reading options do you like available?
  • ◯ Audio books
  • ◯ Have someone read to you
  • ◯ Large print materials
  • ◯ Other______________
Reading Material
  • ◯ Books
  • ◯ Magazines
  • ◯ Newspapers
  • ◯ Mysteries
  • ◯ Romance
  • ◯ Science fiction
  • ◯ Biography
  • ◯ Poetry
  • ◯ Science
Other
  • ◯ Other______________
Q61d. Do you like to be a member of a book club?
  • ◯ Yes
  • ◯ No
Q61e. Do you like to read on an electronic tablet, e-reader, or notebook?
  • ◯ Yes
  • ◯ No
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q62a. Which type of exercise do you like?
Cardio
  • ◯ Biking / cycling
  • ◯ Running
  • ◯ Sporting games
  • ◯ Swimming
  • ◯ Walking
Group classes
  • ◯ Go to exercise class
  • ◯ Go to rehab
Strengthening
  • ◯ Lifting weights
  • ◯ Push-ups
  • ◯ Sit ups
  • ◯ Stretching
  • ◯ Yoga / Tai Chi
  • ◯ Other_________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q63a. Which types of sports have you enjoyed in the past?
Ball sports
  • ◯ Baseball
  • ◯ Basketball
  • ◯ Football
  • ◯ Golf
  • ◯ Tennis
  • ◯ Bowling
Fishing/Hunting
  • ◯ Fishing
  • ◯ Hunting
Physical activity
  • ◯ Boxing
  • ◯ Biking
  • ◯ Swimming
Snow and Ice
  • ◯ Skiing
  • ◯ Hockey
Strengthening
  • ◯ Weight lifting
  • ◯ Yoga / Tai Chi
Walking/Running
  • ◯ Running
  • ◯ Track
  • ◯ Walking
Other
  • ◯ Other_____________
Q63b. Which types of sports do you like now?
Ball sports
  • ◯ Baseball
  • ◯ Basketball
  • ◯ Football
  • ◯ Golf
  • ◯ Tennis
  • ◯ Bowling
Fishing/Hunting
  • ◯ Fishing
  • ◯ Hunting
Physical activity
  • ◯ Boxing
  • ◯ Biking
  • ◯ Swimming
Snow and Ice
  • ◯ Skiing
  • ◯ Hockey
Strengthening
  • ◯ Weight lifting
  • ◯ Yoga / Tai Chi
Walking/Running
  • ◯ Running
  • ◯ Track
  • ◯ Walking
Other
  • ◯ Other_____________
Q63c. Which ways do you like to participate in sports?
  • ◯ Playing sports
  • ◯ Talking about sports
  • ◯ Watching sports
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q64a. Which types of games do you like to play?
Board games
  • ◯ Checkers
  • ◯ Chess
  • ◯ Monopoly
Card games
  • ◯ Bridge
  • ◯ Canasta
  • ◯ Euchre
  • ◯ Go fish
  • ◯ Hearts
  • ◯ Pinochle
  • ◯ Poker
  • ◯ Solitaire
Dice games
  • ◯ Backgammon
  • ◯ Bunco
  • ◯ Yahtzee
  • ◯ Bingo
  • ◯ Dominoes
Tile-laying
  • ◯ Rummikub
  • ◯ Sudoku
Word games
  • ◯ Crosswords
  • ◯ Jumbles
  • ◯ Scrabble
  • ◯ Trivia
  • ◯ Word search
Other
  • ◯ Gambling / games of chance
  • ◯ Jigsaw puzzle
  • ◯ Sporting games
  • ◯ Video games (e.g. Wii)
  • ◯ Other_____________
Q64b. With which people do you like to play games?
Family/Friends
  • ◯ Family_____________
  • ◯ Friends__________
  • ◯ Roommate
  • ◯ Other residents
Staff
  • ◯ Staff
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q65a. In which ways do you like to care for plants?
Education
  • ◯ Learning about plants
Flower Arrangement
  • ◯ Arranging flowers
  • ◯ Picking flowers
Gardening
  • ◯ Caging
  • ◯ Growing flowers
  • ◯ Growing vegetables
  • ◯ Harvesting
  • ◯ Hoeing
  • ◯ Planting
  • ◯ Selecting seeds
  • ◯ Working the soil
Plant Care
  • ◯ Repotting plants
  • ◯ Taking off old blooms
  • ◯ Watering plants
  • ◯ Watching the plants grow from seed
  • ◯ Other__________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q66a. Which ways do you like to be involved in cooking?
Cooking Styles
  • ◯ Baking
  • ◯ Frying or saute'ing
  • ◯ Grilling or barbecuing
Food Prep
  • ◯ Cutting
  • ◯ Garnishing / presenting food
  • ◯ Gathering items
Learning
  • ◯ Attending cooking class
  • ◯ Making / sharing favorite recipes / foods
Other
  • ◯ Setting the table
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q67a. Which type of TV programs do you like to watch?
Current News
  • ◯ News
  • ◯ Sports_______
  • ◯ Weather
Dramas
  • ◯ Mysteries
  • ◯ Dramas
  • ◯ Movies
Entertainment
  • ◯ Cartoons
  • ◯ Comedies
  • ◯ Game shows
  • ◯ Reality TV
Learning
  • ◯ Cooking channel
  • ◯ Documentaries
  • ◯ Nature
  • ◯ Military channel
TV Series
  • ◯ Soap operas
  • ◯ Westerns
Other
  • ◯ Other_____________
Q67b. Write names of favorite programs, if given.
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
LGBT+
Q68a. Which type of movies do you like to watch with other people?
  • ◯ Action / adventure
  • ◯ Comedy
  • ◯ Drama
  • ◯ Horror
  • ◯ Mystery
  • ◯ New releases
  • ◯ Old classic
  • ◯ Romance
  • ◯ War / military
  • ◯ Western
  • ◯ Other_____________
Q68b. Which places do you like to watch movies with other people?
  • ◯ Movie theaters
  • ◯ TV room
  • ◯ Other_____________
Q68c. Which people do you like to watch movies with?
Family
  • ◯ Spouse / significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
Friends
  • ◯ Friends__________
  • ◯ Roommate
  • ◯ Other residents
Other
  • ◯ Other_________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q69a. Which kinds of music do you like?
  • ◯ Big band
  • ◯ Blues
  • ◯ Classical
  • ◯ Country western
  • ◯ Folk
  • ◯ Heavy metal
  • ◯ Hip hop
  • ◯ Jazz
  • ◯ Opera
  • ◯ Religious
  • ◯ Rock
  • ◯ Show tunes
  • ◯ Top 40
  • ◯ Other_____________
Q69b. Do you have a favorite era of music?
  • ◯ Yes
  • ◯ No
Q69b1. If yes, name era of music:
Q69c. Do you have favorite musicians/musical groups?
  • ◯ Yes
  • ◯ No
Q69c1. If yes, name favorite musician/musical group:
Q69d. Which ways do you like to listen to music?
  • ◯ CD player
  • ◯ Computer
  • ◯ iPod, iPhone, iPad
  • ◯ Live music
  • ◯ Radio
  • ◯ Tape / cassette player
  • ◯ Other_____________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q70a. Which activities do you like to do on the computer?
Communicate
  • ◯ Email
  • ◯ Skype
  • ◯ Socialize ________________
Current News
  • ◯ Check the weather
  • ◯ Watch the news
Leisure
  • ◯ Listen to music
  • ◯ Play games
  • ◯ Read
  • ◯ Watch movies
  • ◯ Watch TV shows
Surfing
  • ◯ Research / learn about something
  • ◯ Shop
  • ◯ Other__________
Q70b. Do you like to learn about using the computer?
  • ◯ Yes
  • ◯ No
Q70b1. If yes, what do you like to learn?
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q71a. Which kind of hobbies do you like?
Collecting
  • ◯ Collecting__________________
Creative Arts
  • ◯ Acting
  • ◯ Dancing
  • ◯ Play an instrument__________
  • ◯ Reading
  • ◯ Singing
Writing
  • ◯ Writing
Fine Arts
  • ◯ Ceramics / clay
  • ◯ Drawing / sketching
  • ◯ Painting
  • ◯ Photography
Handiwork
  • ◯ Arts & crafts_________
  • ◯ Beading / jewelry making
  • ◯ Crocheting / knitting
  • ◯ Sewing
Industrial Arts
  • ◯ Fixing things / building things
  • ◯ Models__________
  • ◯ Wood or metalworking
Outdoors
  • ◯ Fishing
  • ◯ Hiking
  • ◯ Picnicking
Other
  • ◯ Other__________________
Notes:
Important
  • ▢ Very important (1)
  • ▢ Somewhat important (2)
  • ▢ Important but can't do, no choice (5)
Not Important
  • ▢ Not very important (3)
  • ▢ Not Important at all (4)
  • ▢ No response/NA (9)
Go toNext Question
Considerations
Q72a. What are your favorite activities?
Q72b. With whom do you like to do your favorite activities?
Family
  • ◯ Spouse / significant other
  • ◯ Children
  • ◯ Brother
  • ◯ Sister
  • ◯ Grandchildren
Friends
  • ◯ Friends__________
  • ◯ Roommate
  • ◯ Other residents
Other
  • ◯ Other_________
Notes:

Custom Detailed Preference Interview

  • Resident Name:
     
  • Interviewer Name:
     
  • Date:
     

"I am going to ask you questions about your preferences. I would like to know what your preferences are right now. Some of the questions may ask about things you feel you can no longer do by yourself, but I'd like to know if these activities would be important to you if you could do them with assistance or find a way to do it."

    • 1=Very Important
    • 2=Somewhat Important
    • 3=Not Very Important
    • 4=Not Important at All
    • 5=Important, But Can't Do, No Choice