Baseline Questionnaire - GeroNet

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23. Were you supposed to take prescribed medication orfollow a prescribed diet for health reasons (This asksif one or both were prescribed, not what the patientdid.)___ Yes___ No24. Wore glasses or contact lenses___ Yes___ No25. A problem with breathing smog or unpleasant air___ Yes___ No26. Any other symptoms, health complaints, or pains thathave not been mentioned?(Describe:___________________________________)___ Yes___ NoD. MOBILITY
1. Did you drive or ride in a car yesterday?___ YesIf yes: Did you use help from another person in orderto drive a car yesterday? If so, why?___ Yes, health related___ Yes, not health related___ No___ NoIf no: Were the reasons you did not drive yesterdayrelated in any way to your health?___ Yes___ No2. Did you use any public transportation yesterday?___ YesIf yes: Did you use help from another person to usepublic transportation yesterday? If so, why?___ Yes, health related___ Yes, not health related___ No___ NoIf no: Were the reasons you did not use public transportationyesterday related in any way to your health?___ Yes___ NoIf no: If you HAD used public transportation yesterday,would you have used help from another person? If so,why?___ Yes, health related___ Yes, not health related___ No
Page 1 and 2: O3base16.fmBASELINE QUESTIONNAIRE T
Page 3 and 4: 5. Does your health now limit you i
Page 5 and 6: 17. During the past 4 weeks did you
Page 7 and 8: 25. During the past 4 weeks, how mu
Page 9 and 10: 33. I expect my health to get worse
Page 11 and 12: ID#________IAPATIENT SATISFACTION Q
Page 13 and 14: 9. All things considered, the medic
Page 15 and 16: 19. I am dissatisfied with some thi
Page 17 and 18: ID#__________IAQUALITY OF WELL-BEIN
Page 19: 11. Trouble talking (e.g. lisp, stu
Page 23 and 24: F. DAILY ACTIVITIES:1. Did you use
Page 25 and 26: ID#___________NIA BATTERY ADMINSTRA
Page 27 and 28: IAID#__________NIA BATTERY ADMINSTR
Page 29 and 30: Health Status Questionnaire (SF-36)

Baseline Questionnaire - GeroNet

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