Personal Preferences Questionnaire
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
DRESSING (How do you dress yourself)
n I can get my own clothing out of the closet / dresser.
n I can put my clothing on without assistance.
n I can put my shoes on without assistance.
n I can manage buttons and zippers without assistance.
➤ Comments:____________________________________________________________________________________
______________________________________________________________________________________________
BATHING AND GROOMING
n I can get in and out of tub/shower by myself
n I can bathe/shower independently
n I need assistance washing certain areas of the body (please specify what areas, e.g., feet, back, etc.)
➤ Comments:____________________________________________________________________________________
______________________________________________________________________________________________
Which do you prefer?
n Bath
n Shower
How many times a week do you have a full bath/shower?_______________________________________________
At what time do you prefer to bathe / shower? (e.g., morning, evening, etc.)_ ________________________________
DINING
a. What time do you usually eat breakfast? __________________________________________________________
b. What do you generally eat for breakfast?__________________________________________________________
c. What time do you usually eat lunch?______________________________________________________________
Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 30
Personal Preferences Questionnaire (Continued)
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
d. What time do you usually eat dinner?_____________________________________________________________
e. Which is your most substantial meal of the day? n Breakfast
f. Do you have a good appetite?
n Yes
n No
g. Do you snack between meals?
n Yes
n No
n Lunch
n Dinner
h. What do you prefer as a snack?
• Morning snack:________________________________________________________________________________
• Afternoon:____________________________________________________________________________________
• Evening bedtime snack:_________________________________________________________________________
i. Have you had a recent weight change?
n Yes
n No
• If yes, please explain:_ __________________________________________________________________________
j. Do you like to cook?_ ___________________________________________________________________________
k. Do you prefer to eat:
n Alone?
n With others?
WALKING
n I can walk with no assistive devices (e.g., cane, walker, etc.)
n I can walk independently with:
n Cane
n Walker
n Other:_ __________________________
n I can walk if someone is with me to ensure my safety
n I can walk short distances (less than 50 ft):
n Without assistance
n With assistance
n I can walk long distances:
n Without assistance
n With assistance
n I enjoy regular walks:
n Without assistance
n With assistance
n I am independent with my wheelchair
n I need to be pushed in my wheelchair
➤ Comments:____________________________________________________________________________________
______________________________________________________________________________________________
Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 31
Personal Preferences Questionnaire (Continued)
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
DAILY ROUTINE
a. What time do you wish to get up in the morning?___________________________________________________
b. What time do you get dressed in the morning?_____________________________________________________
c. Do you nap during the day?
n Yes
n No
• If yes, what time?___________________ For how long?____________________
d. What time do you go to bed at night?_ ____________________________________________________________
e. Do you generally sleep through the night?
n Yes
n No
n Yes
n No
• If no, do you: waken to go to bathroom:
f. Where do you sleep at night?
n Bed
n Chair n Sofa
How many times?_____________________
n Other____________________________
• (Please explain:)_ ______________________________________________________________________________
g. In your present bedroom, is one side of your bed placed against the wall? n Yes
n No
n Right
• If yes, which side (as you are lying in the bed) is against the wall?
n Left
h. Do you have someone come in during the day or night to assist with meal preparation,
household chores, personal care, etc.?
• If yes, who?___________________________________________________________________________________
• With what types of things does this person assist you?________________________________________________
______________________________________________________________________________________________
n Yes
n No
i. Which of the following do you do during a typical day? (Please check all that apply)
n Go out (shopping, visiting, etc.)
n Hobbies (Please specify:)_ ______________________________________________________________________
n Other (Please specify)__________________________________________________________________________
j. Do you smoke? n Watch T.V.
n Yes
n Read
n Do crafts
n No
• If yes, how many cigarettes do you smoke per day? __________________________________________________
Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 32
Personal Preferences Questionnaire (Continued)
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
k. Do you enjoy a cocktail?
n Yes
n No
• If yes, what time of day do you enjoy your drink? ____________________________________________________
• If yes, how often do you have a cocktail? __________ per day __________ per week
TRANSFERRING
n I can get out of and into bed on my own.
n I can go from the bed to a chair and vice versa, with no assistance.
n I need assistance to get in and out of bed or a chair.
n I need total assistance with transfers (i.e., mechanical lift)
➤ Comments:____________________________________________________________________________________
______________________________________________________________________________________________
TOILETING
n I can toilet myself without assistance
n I need a raised toilet seat
n I can care for myself after toileting
n I am continent, but need assistance with hygiene.
n I am incontinent, but use protective pads and can change them myself
n I am incontinent, but need assistance with incontinent products.
PAIN ASSESSMENT
a. Do you have any discomfort / pain?_______________________________________________________________
*Please note: if answering on behalf of the prospective resident due to his / her cognitive impairment, indicate nonverbal
signs of pain, such as behavior changes, facial expressions, changes in mood, verbal cues that we should be aware of.
➤ Comments:____________________________________________________________________________________
_______________________________________________________________________________________________
Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 33
Personal Preferences Questionnaire (Continued)
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
b. If you have pain, indicate location of pain:_________________________________________________________
______________________________________________________________________________________________ c. Is pain of such intensity that it limits your ability to be independent in your care?
n Yes
n No
d. When do you experience discomfort / pain?________________________________________________________
What do you do to alleviate the discomfort / pain? n Medication n Topical ointment n Hot/cold treatment
n Other (explain)_______________________________________________________________________________
e. Is the treatment you use effective? To what degree: n Yes
n No
n Somewhat n Moderate n Total relief
f. If you do get relief from discomfort / pain, how long are you pain-free before requiring more treatment?
______________________________________________________________________________________________
ACTIVITIES
a. Do you actively participate in any community / church organizations?
n Yes
n No
If yes, please specify:_____________________________________________________________________________
______________________________________________________________________________________________
b. Are there any activities in which you participate at least weekly?
n Yes
n No
If yes, please specify_ ____________________________________________________________________________
c. Do you prefer to: (check all that apply)
n Socialize in small groups? n Socialize in larger groups?
n Pursue solitary activities? n No preference?
d. Do you belong to any particular church or synagogue?
n Yes
n No
e. Do you find strength in religion?
n Yes
n No
f. Do you vote in local, state, and national elections?
n Yes
n No Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 34
Personal Preferences Questionnaire (Continued)
PATIENT’S NAME:_______________________________________________________________
Please check all items in each category that describe your abilities and leave blank those items that do not apply to you.
MEDICAL INFORMATION
a. Do you have any allergies to food or medications? n Yes
n No
If yes, please explain:_____________________________________________________________________________
______________________________________________________________________________________________
b. Do you take your own medication?
n Yes
n No
c. Where do you keep your medications? ____________________________________________________________
Medicine Cabinet Kitchen
n Yes
n No
n Yes
n No
d. When do you prefer to take your medications?_____________________________________________________
With meals _________________ Before____________________ After meals ________________
e. How often do you take your medications? _________________________________________________________
GENERAL QUESTIONS
a. Do you mind having someone assist you with personal care (e.g., bathing, toileting, etc)?
b. Do you ever have difficulty finding your way around?
c. Do you like animals?
n Yes
n No
n Your neighborhood
n No
If yes, what kind of animals do you like? _____________________________________________________________ d. Do you have any allergies to animals?
n Your house
n Yes
n Yes
n No
If yes, please explain:______________________________________________________________________
NAME OF PERSON COMPLETING FORM:_____________________________________________________________
RELATIONSHIP:_ __________________________________________ DATE: ______________________________
Tool prepared by AIPP Culture Change Project
AIPP BASIC BLUEPRINT FOR IMPLEMENTING CULTURE CHANGE • 35