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
SOCIAL ACTIVITIES
CARE PROVIDERS
The next set of questions is about social activities. I’ll be asking you some questions about the things you like to do with other people. Some of the statements may
ask about things you feel you can no longer do, but I’d like to know whether you would enjoy these things if you could do them, for example, if you were healthy
enough or with assistance.
[Any time the respondent states that they can no longer do something, remind them to imagine they are healthy enough to do these things or that they have
the assistance to do them. You should encourage the respondent to “imagine that you could do anything you wanted to.”]
Comments
Comments
1.
Do you like spending time with large groups of people?
2
Do you like spending time by yourself?
3
Do you like being a member of clubs, committees, and other
organizations?
not at all
not at all
not at all
a little
a little
a little
some
alot
some
some
alot
alot
no pref
no pref
no pref
N/A
N/A
N/A
[IF “NOT AT ALL” SKIP TO 4]
1
4.
not at all
Do you like to keep in regular contact with your family?
a little
some
alot
no pref
N/A
[IF “NOT AT ALL” SKIP TO 5]
Comments
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?
First Name
Relationship
Relationships:
1 = spouse/partner
2 = child
3 = sibling
4 = in-law
5 = grandchild
6 = niece/nephew
7 = other (specify)
5.
Do you like touching someone you care about?
Do you like the following kinds of physical contact?
a.
b.
c.
d.
shaking hands…………………………………………………..
holding hands………………………………………………….
sitting close together……………………………………….
hugging………………………………………………………….
Mode(s)
of contact
Total frequency of
contact
Mode:
1 = phone
2 = cards/letters
3 = 4-mail
4 = I visit them
5 = they visit me
6 = live with
7 = other (specify)
not at all
a little
some
Frequency:
1 = daily
2 = 2-3 times/week
3 = weekly
4 = 2-3 times/month
5 = monthly
6 = every few months
7 = on holidays
alot
no pref
N/A
[IF “NOT AT ALL” SKIP TO 6]
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
2
e. kissing…………………………………………………………….
f. getting a back rub…………………………………………….
g. other: (specify)………………………………………………..
no
yes
no pref
N/A
no
yes
no pref
N/A
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?
not at all
a little
some
alot
no pref
N/A
Do you like the following kinds of animals:
a.
b.
c.
d.
e.
dogs…………..…………………………………………………..
cats…………….………………………………………………….
fish……………………….……………………………………….
birds…..………………………………………………………….
other: (specify)………………………………………………..
[IF “NOT AT ALL” SKIP TO o]
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
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…………………………………………………………..
g. holding in lap………………………………………………….
h. playing with……………………………………………………
i. feeding…………………………………………………………..
j. walking…………………………………………………………..
k. training………………………………………………………….
l. watching…………………………………………………………
m. animal as guard……………………………………………….
n. would you like to have a pet now?………………………
o. when was the last time you had a pet?…………………
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
N/A
3
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?….……………………………
If yes, what kind(s)?_________________________________
s. Are you afraid of animals?………………………………….
If yes, what kind(s)?_________________________________
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
no
yes
no pref
N/A
OTHER ACTIVITIES
We’re almost finished now. This is the last section, and it includes questions about other things that you do for leisure and other
things about yourself. Again, some of the questions may ask about things you feel you can no longer do, but I’d like to know
whether you would enjoy these things if you could do them, for example, if you were healthy enough or with assistance.
[
Any time the respondent states that they can no longer do something, remind them to imagine they are healthy enough to do these things or
that they have the assistance to do them. You should encourage the respondent to “imagine that you could do anything you wanted to.” For
respondents with blindness or paralysis, if there is any possibility that they could do something, please ask the questions. For instance, just
because someone is blind does not mean they would not like watching TV, so you would ask these questions. If there is no possibility they
could do something (e.g., a paralyzed person cannot walk) skip the item.]
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]
4
a. Do you like to exercise in the…
1.
2.
3.
morning…………………………………………………
afternoon……………………………………………….
evening………………………………………………….
no
no
no
yes
yes
yes
no pref
no pref
no pref
N/A
N/A
N/A
Do you have an interest in, or think you would have an interest in the following kinds of activities?
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
2.
walking………………………………………………………….
biking……………………………………………………………
swimming………………………………………………………
calisthenics/stretching……………………………………..
yoga/tai chi…………………………………………………….
stair climbing………………………………………………….
racquet sports…………………………………………………
bowling…………………………………………………………
weight lifting ………………………………………………..
golf ……………………………………………………………..
other (specify)………………………………………………..
Do you like to participate in religious/spiritual activities?
no
no
no
no
no
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
not at all
no pref
no pref
no pref
no pref
no pref
no pref
no pref
no pref
no pref
no pref
no pref
a little
some
alot
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
no pref
N/A
[IF “NOT AT ALL” SKIP TO #3]
no pref
a. What is your religion?
N/A
Do you like to do the following religious/spiritual activities:
b.
c.
d.
e.
f.
g.
attend religious services…………………………………..
pray………………………………………………………………
read scriptures……………………………………………….
listen to radio services or audiotapes of services….
watch services on TV………….…………………………….
observe food restrictions because of your religion.
no
no
no
no
no
no
1
1
yes
yes
yes
yes
no pref
no pref
no pref
no pref
no pref
no pref
N/A
N/A
N/A
N/A
N/A
N/A
What kind of restrictions?
5
h.
have visits from clergy…………………………………….
no
yes
no pref
N/A
no pref
N/A
no pref
N/A
Visits from whom?
i.
Receive holy communion [Do not ask this question if respondent is Jewish or Muslim.]
no
j.
Are there any other religious/spiritual activities you
enjoy?
no
yes
yes
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.
b.
c.
d.
e.
f.
country…………………………………………………………
jazz………………………………………………………………
blues…………………………………………………………….
religious (hymns, gospel, klezmer)……………………..
classical…………………………………………………………
big band (Mitch Miller, Lawrence Welk)………………..
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
no pref
no pref
no pref
no pref
no pref
no pref
N/A
N/A
N/A
N/A
N/A
N/A
6
g.
h.
i.
j.
k.
l.
show tunes……………………………………………………
opera……………………………………………………………
popular/contemporary (Top 4no)…………………………
rock……………………………………………………………..
folk ……………………………………………………………..
other (specify)……………………………………………….
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
no pref
no pref
no pref
no pref
no pref
no pref
N/A
N/A
N/A
N/A
N/A
N/A
m.
Do you have favorite musicians?
no
yes
no pref
N/A
no
no
no
no
no
yes
yes
yes
yes
yes
no pref
no pref
no pref
no pref
no pref
no pref
N/A
N/A
N/A
N/A
N/A
N/A
no
no
yes
yes
no pref
no pref
N/A
N/A
If Yes, specify:
Do you like to listen to music in the…
n.
o.
p.
q.
r.
s.
t.
5.
morning………………………………………………………..
afternoon……………………………………………………..
evening…………………………………………………………
late night………………………………………………………
Do you like to play a musical instrument?……………
What instrument(s)
________________________________
Do you like to sing?…………………………………………
Do you like to dance?………………………………………
What kind of dancing?
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
7
6.
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
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…
8
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?
not at all
a little
some
alot
no pref
N/A
Do you like to listen to the radio in the…
[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
9
d.
late night………………………………………………………
no
yes
no pref
N/A
On the radio, do you enjoy listening to…
9.
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
Do you like reading?
not at all
2
some
alot
no pref
N/A
[IF “NOT AT ALL” SKIP TO o]
Do you like to read 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 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
10
10.
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
Do you like cultural activities such as concerts, theater, and
not at all
a little
some
alot
no pref
N/A
museums?
[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
no pref
N/A
[IF “NOT AT ALL” SKIP TO h]
Do you enjoy going to museums of…
d.
art…………………………………………………………………..
no
yes
no pref
N/A
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
O10d
11
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
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?
13