interview assignment

Assignment: An Interview about the Later Life of a Senior Citizen (60 Year Old and over) Instruction: Conduct an interview with an older adult and write a summary report ( A document guideline can be found on page 5 of the course syllabus) I. Demographics Age ____________ What is your gender? ___ Male ___ Female Marital status ________________ Ethnicity ____________________ Place of birth _________________ Current Residential Zip code___________

What is the highest education you have completed ? ____ Less than high school ____ High school Graduate ____ Some college ____ Bachelor’s degree

____ Master ‘s degree ____ Doctoral degree ____ Other (please specify ____________)

What is your annual household income or pension? ____ under $10,000 ____ $10,001 - $20,001 ____ $20,001 - $30,000 ____ $30,001 - $40,000

____ $40,001 - $50,000 ____ $50,001 - $60,000 ____ Over $60,000

II. Your Health Status

1. Do you suffer any form of chronic diseases? Yes ________ No________ If yes, please specify_______________

2. Do you take any prescribed medicines?

Yes________ No___________ 3. Do you smoke?

Yes________ No___________ 4. Do you drink alcohol?

Yes________ No___________ 5. Do you have any form of disability that prevents you from participating in activities?

Yes ________ No________

6. Do you use any assistive device to walk around? None_______ Walker _____ Wheelchair _____ Other, specify __________

7. Have you experienced any fall resulting in a bone fracture? Yes_________ No_________ 8. Have you suffered any injury in the past 12 months? Yes_________ No_________ If yes, what was cause ____________________? 9. How tall are you __________? What is your weight __________? 10. Do you agree with the following statements? Circle 1 to indicate strongly disagree and 5 represent strongly agree In general, you feel good about

Strong disagree

Disagree Neutral Agree Strong agree

Your health condition 1 2 3 4 5 Your physical condition 1 2 3 4 5 Your energy level 1 2 3 4 5 Your endurance level 1 2 3 4 5 Your mobility 1 2 3 4 5 Joint conditions 1 2 3 4 5 You visual ability 1 2 3 4 5 Your heart condition 1 2 3 4 5 Your respiratory system 1 2 3 4 5

III. Your Leisure Life Style

1. Which place do you frequently visit for leisure purpose? (i.e. park, library…) 2. How often do you visit such a place?

___Never ___Less than 1 time a month ___1 time a month ___2 times a month

___3 times a month ___4 times a month ___More than 4 times a month

3. What did you do while you were there? _____________________________

4. Do you take a walk for exercise? (If yes ____, go to next question) (If no____, what do you do for exercise? _________________ and skip to question 7)

5. How often do you walk during a month?

___Less than 1 time a month ___1 time a month ___2 times a month

___3 times a month ___4 times a month ___More than 4 times a month

6. How long do you usually walk?

___Less than 30 minutes ___30-60 minutes ___1hour - 1.5 hours

___1.5 hours -2 hours ___More than 2 hours

7. Do you think it is worthwhile to participate in leisure activity? Yes____ No____ Why? ___________________________________________________________ 8. How frequently do you visit your friends/relatives?

___Never ___Less than 1 time a month ___1 time a month ___2 times a month

___3 times a month ___4 times a month ___More than 4 times a month

9. Do you agree with the following statements? Circle 1 to indicate strongly disagree and 5 represent strongly agree Strong

disagree Disagree Neutral Agree Strong

agree you can count on a person to console you

1 2 3 4 5

There is a person make you feel liked or loved

1 2 3 4 5

you can confide in this person

1 2 3 4 5

When you are out of town, someone will help you to take care of your belongings or property

1 2 3 4 5

you have someone to spend your leisure time together

1 2 3 4 5

If you have question, you have someone to ask

1 2 3 4 5

you have someone to give you advice when you need it

1 2 3 4 5

You have someone to ask when you are not sure what to do

1 2 3 4 5

Your companion makes you feel good

1 2 3 4 5

your companion makes you feel respected

1 2 3 4 5

If you need something, someone will lend to you

1 2 3 4 5

If you need a ride to the doctor, someone will give you a lift

1 2 3 4 5

If you were confined to bed, someone will assist your lives

1 2 3 4 5

10. Do you have someone to talk to when you feel lonely? Yes_____ No_____ 11. How do you make a contact with this person? ___Phone calls ___visits ___email

___letters ___others, please specify_________

12. Who is this person? (Mark all that apply) ___Spouse/partner ___Family member/relatives ___friends ___school/work associates

___neighbor ___health provider ___therapist ___others, please specify__________

IV. Your Travel Activities

1. Have ever taken a vacation trip to somewhere during the past 12 months? Yes ________ (if yes, where did you go _______________________________) No_________ 2. Which of the followings you have visited in the last 12 months? (mark all that

apply) ___museum ___historical relics ___nature center ___spa vacation ___national park ___art exhibition ___community festival ___senior center ___movie theater

___restaurant ___park ___mall ___concert ___library ___international travel ___visit friends out of town ___Other, please specify__________

3. Which of the following places you plan to visit in next 12 month? ___museum ___historical relics ___nature center ___spa vacation

___national park ___art exhibition ___community festival ___senior center

___movie theater ___a restaurant ___a park ___a mall ___concert

___library ___international travel ___visit friends out of town ___Other, please specify__________

4. What is your motivation to visit this place? ___Get away from routine ___Meet new friend ___Spend time with family/relatives ___Spend time with friends ___Visit the place I love ___like to visit a new place

___Learn more about the visiting subject ___Release my stress ___Want to have some exercise ___Want to learn different culture ___Other, please specify _________

5. How many nights do you usually spent in lodge facilities on a trip? _____

6. When you were on a leisure trip, had you ever suffered any of the following health problems? Diarrhea due to food/water Yes No Vomiting/upset stomach from drinking water

Yes No

Sunburn Yes No Infections due to injury Yes No Insect bite Yes No Nausea due to high elevation Yes No Other? Please be specify:

7. May/might any of the following reasons prevent you from taking a vacation tour?

Strong disagree

Disagree Neutral Agree Strong agree

No interest to travel at all 1 2 3 4 5 No money to travel 1 2 3 4 5 No one to go with me 1 2 3 4 5 Don’t know where to go 1 2 3 4 5 No time to travel 1 2 3 4 5 I will go if my family members go with me

1 2 3 4 5

I am too old to travel 1 2 3 4 5 I can’t drive a car anymore 1 2 3 4 5 I don’t like to meet stranger 1 2 3 4 5 My health can not afford me to travel

1 2 3 4 5

8. Any thing else would you like to add about your leisure lives? _______________________________________________________________